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LIBRARY OF CONGRESS. 

Chap. Copyright No. 

Shell 3Ql2^- 



UNITED STATES OF AMERICA. 



*^ RECEIVED * 

V JUN 10 M§» 





^^rw*yv*v> 



YELLOW FEVER. 



CLINICAL NOTES 



BY 



JUST TOUATRE, M. D. (Paris), 

Former Physician-in-Chief of the French Society Hospital, New 

Orleans; Member of Board of Experts, Louisiana 

State Board of Health. 



TRANSLATED FROM THE FRENCH 



BY 



CHARLES CHASSAIGNAC, M. D., 

President NewOrleans Polyclinic ; Editor New Orleans Medical 
and Surgical Journal, etc. 



new orleans: 
New Orleans Medical and Surgical Journal, Ltd, 

1898. 




2nd CC 

1896. ^^^10 \ 



•^ 



S1SS 



Copyright, 1898. 

JUST TOUATRE, 

New Orleans. 



PRESS OF 

L. Graham & Son, Ltd. 

NEW ORLEANS. 



TRANSLATOR'S NOTE. 



The legend " translated from the French," which 
appears on the title page, would probably be miscon- 
strued if no explanation followed. It might be sup- 
posed that this work had previously been published in 
the original text. 

Such is not the case. This is the original edition. 
Dr. Touatre wrote it in his mother tongue because he 
modesth r thought his English not equal to the task. 

I fear he was mistaken, as I feel that in the trans- 
lation much has been lost in point of style. I have 
carefully followed the text, however, and believe that 
the author's ideas have be en faithfully reproduced. 

C. C. 



INTRODUCTION. 



During nearly twenty years, ever since Pasteur's 
immortal discoveries, the activity and the genius of 
young physicians have been devoted to the search for 
pathogenic microbes ; to unceasing investigations 
upon their method of life, of development, of pros- 
pering, and of doing harm ; and to the minute study 
of their associations, combinations, and, especially, 
of the poisons they manufacture. 

The study of the patient, without being neglected, 
no longer holds the first place, and the clinical work 
on Yellow Fever I am now submitting to the judgment 
of the medical public may appear to some not suffi- 
ciently fin de siecle. 

It might have had better chances of success twenty 
years ago, but I believe it can be of great service even 
to-day. I shall not quote the French proverb which 
says that experience surpasses science, for the two are 
indispensable in the practice of Medicine. 

The wonderful work achieved in the laboratories 
deserves all of our admiration, and physicians and 
surgeons both profit by it daily in curing their 
patients ;. yet, if knowing the cause of a disease is of 
the highest importance, it is also necessary to know 
how the organism, as a whole, how its cells, its organs 
and its functions are affected by the pathogenic 
microbe and its virus. 



vi Introduction. 

It is at the bedside that we learn the course of the 
disease, the value or importance of a symptom, and 
the propriety or urgenc\- of such and such medication. 
Hence, I believe that while it is necessary to keep an 
eye on the microbe, the enemy, both eyes must be 
kept wide open on the patient, the victim. 

Sanarelli's discovery of the bacillus icteroides and 
his valuable explanator}- works certainly throw light 
in some dark corners of the study of Yellow Fever, 
but they also bring out in relief previously acquired 
clinical ideas. 

Bacteriology and Practice must march hand in hand 
and assist each other ; for, if the culture tube and the 
microscope increase our knowledge and make it more 
precise, it is Medicine which must apply the new- 
born truths to the cure of the patient and the clinician 
must remain the high-priest of Medicine. Because 
long range cannons and melinite shells are now 
manufactured does not mean that the gunner handling 
the piece has lost his skill. 

Convinced that clinical observation and its lessons 
may enlighten the physician, and, in consequence, 
render important services to the patient, and urged by 
a few friends, I have written this monograph, con- 
densing in as clear a manner as possible the experi- 
ence acquired while treating over two thousand 
patients attacked by Yellow Fever. 

I am not a great bibliographer it is true, but I have 
no knowledge of any book treating this disease solely 
from a clinical standpoint. All treatises on Yellow 
Fever are didactic, and refer particular!}' to patholog3 T ; 



Introduction. vii 

a morbid entity, the front aspect of typhus icteroides, 
is described, while I penetrate into the interior and 
nose into all the little corners. 

A member of the Board of Experts of the Louisiana 
Board of Health, I had the opportunity, during the 
epidemic of 1897, t0 realize that many young physi- 
cians of instruction and ability, who had properly 
studied Yellow Fever in the books, knew little of the 
disease. This is not a reproach, as I have been in 
the same boat. Forty years ago Faget called atten- 
tion to the fall in pulse rate ; twenty-five 3-ears ago he 
promulgated the law of the divergence between pulse 
and temperature, which bears his name ; yet these two 
symptoms, which are observed only in Yellow Fever, 
which characterize it and are pathognomonic, are 
very little known, imperfectly observed and badly 
appreciated. 

Faget's name must be inscribed with letters of gold 
in the history of Yellow Fever, as is that of Bouillaud 
in the history of rheumatism ; long before the time of 
Pasteur and of Sanarelli he had called attention to the 
specificity of Yellow Fever by studying the disease 
with the watch and the thermometer ; if the labors of 
that eminent physician have not obtained the recog- 
nition they deserve, it may be because his discoveries 
were presented in a manner perhaps too didactic. I 
shall attempt to make them better known, and to 
demonstrate their whole value. 

I shall even enlarge and treat in its entirety the 
question of temperature in Yellow Fever, which 
regulates everything, the diagnosis, the prognosis and 



viii Introduction. 

the treatment. Forty-six clinical charts of the pulse 
and temperature are published, together with the bed- 
side observations and comments thereon ; they form 
an interesting collection, which I believe very instruc- 
tive, as it includes all types, forms and varieties of 
Yellow Fever at all periods of life. They form the 
most original and, I believe, the most useful part of 
my clinical notes. 

I have written a long chapter on the Yellow Fever 
of children, with observations ; it should settle the 
•question, yet discussed by some stragglers, as to 
whether they get this fever or not. 

The diagnosis of Yellow Fever is usually easy, but 
I have devoted a long chapter to it because it is 
important at the outset of the disease to make, not 
only the diagnostic label, but the diagnosis of the 
patient. 

A study of the history of the last thirty-three epi- 
demics which have prevailed in New Orleans has 
led me to formulate two laws which I believe very 
important and which I have developed in the chapter 
on prognosis. I call the reader's attention to this 
chapter, as I believe it very suggestive. 

Finally, I have described minutely the treatment 
to which I resort and why I do so. In all the books 
on Yellow Fever one reads, in the chapter on treat- 
ment : " Everything has been tried, nothing has suc- 
ceeded. ' ' This pessimism is heartrending as well as 
entirely false. 

Good treatment yields excellent results and the 
physician is just as well armed for battle against 



Inroduction. ix 

Yellow Fever as against any other disease. How- 
ever, he must act promptly and begin the defence 
immediately after the attack. 

" Macaque toujours trouve so piti joli,"* but, 
making allowance for the excellent opinion which an 
author always has for his book, I believe that my 
thirty -three years of study and the nine epidemics 
through which I have passed, have allowed me to 
observe many shades and note many peculiarities 
which few physicians have seen and. to become 
intimately acquainted with Yellow Fever. 

At my age, on the eve of my return to France after 
thirty-three years of the practice of Medicine in New 
Orleans, I seek ni honor ni argentum. My only desire 
is, if possible, to leave to this country, which has 
been so hospitable to me, a useful book as a token ol 
gratitude. 

Just Touatre. 



* A Creole proverb, meaning that even a monkey finds its child pretty. 



TABLE OF CONTEXTS. 



CHAPTER I. 

General Observations. 

Page. 
How to proceed in order to recognize the disease 

promptly i 

Interrogatory of patient 4 

Duration of disease 6 

CHAPTER II. 

S\ ' mp to m a tolog) ' . 

Symptoms of invasion S 

Symptoms of disease proper 10 

Symptoms of termination 12 

Fulminating invasion 17 

Cephalalgia iS 

Rachialgia 18 

Xausea and vomiting 19 

Hemorrhage 20 

Icterus 24 

The urine and albuminuria 25 

Pulse and temperature 2>° 

CHAPTER III. 

Fall in Pulse Rate — Faget 's Law — Clinical Charts of 
the Pulse and Temperature — Types and Variations 
of Yellow Fever. 

Observations 36 

Charts Xos. 1 and 2 — Mild Yellow Fever 42 



xii Table of Contents. 

Page. 

Charts Nos. 3 and 4 — Mild Yellow Fever 44 

Chart No. 5 — Mild Yellow Fever — Complication . 46 

Chart No. 6 — Yellow Fever of moderate intensity.. 48 

Chart No. 7 — Severe Yellow Fever 50 

Chart No. 8 — Yellow Fever of moderate intensity . 52 
Chart No. 9 — Yellow Fever of moderate intensity 

and remittent 54 

Chart No. 10 — Grave remittent Yellow Fever 56 

Chart No. 11 — Very grave Yellow Fever 58 

Chart No. 12 — Grave Yellow Fever 60 

Chart No. 13 — Pure Yellow Fever — Black Vomit 62 
Chart No. 14— Yellow Fever with Acute Nephri- 
tis — Black Vomit and Anuria 66 

Chart No. 15 — Fatal Yellow Fever without Black 

Vomit 68 

Chart No. 16 — Pure Yellow 7 Fever — Ver} r Virulent 70 

Chart No. 17 — Pure Yellow Fever 72 

Chart No. 18 — Fatal Yellow Fever — Organic 

Weakness 74 

Chart No. 19 — Patient in Feeble Health and 

Slightly Alcoholic 76 

Charts Nos. 20 and 21 — Yellow Fever with Alco- 
holism and Nephritis 78 

Charts Nos. 22 and 23 — Yellow Fever with Alco- 
holism and Nephritis 80 

Charts Nos. 24 and 25 — Yellow Fever in the 

Alcoholic 82 

Chart No. 26 — Very Grave Yellow Fever — 

Tj^phoid Aspect 84 

Chart No. 27 — Very Grave Yellow Fever — 

Patient 40 Years of Age 86 

Chart No. 28 — Yellow Fever and Alcoholism — 

Atypic Curves 88 

Chart No. 29 — Grave Yellow Fever — Black Vomit 90 
Chart No. 30 — Yellow Fever — Pregnane}' — Sup- 
purative Parotiditis 92 

Chart No. 31 — Very Grave Yellow Fever — 

Ecthyma Pustules — Sloughing 94 



Table of Contents. xiii 

Page. 

Chart No. 32 — Very Grave Yellow Fever — Black 

Vomit 96 

Chart No. 33 — Yellow Fever and Malaria 98 

Chart No. 34 — Mild Yellow Fever — Relapse 100 

Chart No. 35 — Very Grave Yellow Fever — Very 

Serious Relapse — Black Vomit both times 102 

Conclusions 104 



CHAPTER IV. 

Yellow Fever in Children — Clinical Charts of Pulse 
and Temperature. 

Observations 108 

Charts Nos. 1 and 2 — Mild Yellow Fever 112 

Charts Nos. 3 and 4 — Yellow Fever of Moderate 

Intensity 1 14 

Charts Nos. 5 and 6 — Yellow Fever of Moderate 

Intensity 116 

Charts Nos. 7 and 8 — Grave Yellow Fever 118 

Chart No. 9 — Grave, Remittent Yellow Fever.... 120 
Charts Nos. 10 and 11 — Yellow Fever of Great 

Gravity 122 

Conclusions 124 



CHAPTER V. 

Diagnosis. 
Diagnosis of Yellow Fever 125 

CHAPTER VI. 

Prognosis. 

Prognosis of Yellow Fever 143 



xiv Table of Contents. 

CHAPTER VII. 

Treatment. 

Page. 

No Specific, but other means 163 

Medication 167 

Aeration of the Room 169 

Clinical Observations and Recommendations 172 

Treatment of the Period of Congestion and 

During the Course of the Disease 173 

Foot Bath a la Creole 174 

Cold Sponging 176 

Cold Baths 181 

For Vomiting 187 

Diet 188 

Drink 189 

What Not to Do 196 

Treatment During Period of Infection 200 



CHAPTER I. 



GENERAL OBSERVATIONS. 



When, during an epidemic of Yellow Fever, a 
physician is called to the bedside of a patient, 
how must he proceed in order to recognize the 
disease promptly, to follow its course intelli- 
gently, and, especially, to seize at the earliest 
moment the indications for a useful and effi- 
cacious treatment ? 

He must at the outset be supplied with a 
thermometer, a watch with second hands, and 
a clinical chart ; on the latter he must note, at 
least twice a day, all the symptoms observed, 
as well as the degree of fever, the number 
of pulsations, the amount of urine voided in 
twenty-four hours, and the results of the uri- 
nary analyses. 

A complete clinical record, kept in writing 
and carefully taken, is of the highest impor- 
tance. I can not insist too much upon this, 
for, during an epidemic, when one has from 



2 Yellow Fever. 

fifteen to twenty patients or more to visit at 
least twice a day, it is absolutely impossible to 
remember the course, of Yellow Fever, be it 
natural or irregular, in each patient. Hence, 
to the patient's great detriment, the disease is 
gauged from day to day, visit by visit, instead 
of being appreciated at the outset in its en- 
tirety. 

Also, it is only after having gathered nu- 
merous observations, and by studying and 
comparing them, that the physician gets to 
know Yellow Fever in all its forms, its differ- 
ent types, at all ages, in all its variations, etc., 
and to acquire the necessary experience to 
treat this disease, which certainly is one of 
the most difficult, not only to observe well, but 
especially to treat well. 

Yellow Fever presents symptoms which, 
when grouped and seen in block, make of it 
a perfectly typical affection resembling no 
other morbid entity, just as typical- as Variola 
or Cholera. 

At the bedside, however, the symptoms ap- 
pear only in succession ; the physician must 
consequently know thoroughly all the symp- 
toms of Yellow Fever, and especially their 
succession, how to appreciate them, compare 



General Observations. 3 

them, and gauge them properly. The best 
method is to note them in writing, at each visit, 
as they appear in the patient. 

The physician must never forget that Yel- 
low Fever is an acute bacillary disease, with 
very virulent toxins, and of very rapid course, 
carrying away the patient the third or fourth 
day in very grave cases, on the sixth and sev- 
enth day in grave ones. 

It is often certainly as virulent as Hemor- 
rhagic Variola, Gangrenous Scarlatina, the 
Plague and Cholera. Hence, it is not when 
the infection is striking and complete, when 
the hepatic cells are degenerated, when the 
kidneys are closed, when the capillary vessels 
rupture and the patient has black vomit, that 
the physician can assist him. It is within 
the first seventy-two hours of the disease that 
medication may be potential and bold ; but, in 
order that the treatment may be enlightened, 
appropriate, and energetic, the physician must 
perceive the pressing indications from the 
observation and appreciation of the symptoms ; 
from, especially, the stomach and the kidneys, 
in order to obviate the patient's danger, or at 
any rate to diminish it. 

For in Yellow Fever the struggle between 



4 Yellow Fever. 

the organism and the microbe is merciless. 
The combat is eager and fnrions, fnll of tragic 
emotions, bnt often terminates in the victory 
of the organism, especially if the physician, 
instead of giving play to the microbe by ill- 
timed medication, is an enlightened auxiliary 
and a vigilant and well-armed ally. 

Interrogatory of the Patient. — In Yel- 
low Fever all information is useful. 

At the first visit the patient must be asked his 
age ; his birthplace ; whether he has passed 
through Yellow Fever epidemics ; wmether he 
has been ill during such epidemics ; if he has 
had other infectious diseases, such as Typhoid 
Fever, Scarlatina, etc. Information must be 
sought as to his habits ; as to whether he nour- 
ishes well, whether he indulges in alcoholic 
drinks ; as to his trade or profession ; whether 
he fatigues himself ; whether he works at night, 
or commits excesses and of what kind. 

In fact, it is necessary by a complete inter- 
rogatory to judge what is likely to be the 
amount of his organic resistance and to know 
how well armed he is for the battle which is 
beginning and whose stake is his life. 

All these investigations are of the highest 
importance, as, for instance, in the child or 



General Observations. 5 

adolescent free from hereditary or acquired 
taint, Yellow Fever is always very mild if no 
resort is made to disturbing medication ; in the 
alcoholic, Icteroid Typhus is always very grave 
and most frequently fatal. In a patient who has 
passed the forty-fifth year and whose vitality 
is always sapped, no matter how good the 
health may be, Yellow Fever is always as 
dangerous as it is light in childhood. I have 
rarely seen a patient beyond his fiftieth year 
recover. 

Yellow Fever is like fortune, it does not 
love the aged, and the simplest lesion of the 
stomach, the liver, or especially of the kid- 
neys, increases the gravity of the disease. 

All these ideas must be well known and 
well classified in the physician's mind. 

In each case there are two factors. First, 
the microbe and its toxin, more or less viru- 
lent ; second, the patient, a good or bad culture 
medium, according to the lesser or greater 
resistance of his organism. 

A point to be carefully noted always is the 
exact hour of the outset of the disease. 

Yellow Fever sometimes, say in fifteen or 
twenty per cent, of the cases, begins in a mild, 
insidious manner. The patient does not take 



6 Yellow Fever. 

the bed, goes out, eats as usual; and those 
imprudences are disastrous, as the disease is 
always aggravated under those circumstances. 
When finally compelled to go to bed, he dates 
the beginning of the disease from that time. 
This information is incorrect, and must always 
be investigated carefully, for deceiving the 
physician may be prejudicial to the patient. 
The view of the case on the first day is unlike 
that reached on the second or third day, and 
the treatment varies accordingly. 

Duration of the Disease — Succession 
of Symptoms. — Yellow Fever is a cyclic dis- 
ease, lasting ordinarily an average of eight to 
ten days. The symptoms appearing at the 
outset become aggravated or attenuated, are 
blotted out and disappear, to be replaced by 
others. 

This succession of symptoms is very impor- 
tant, and must be well mastered in order to 
avoid many errors of judgment and of treat- 
ment. 

The patient's physiognomy changes from 
day to day, but the disease is always one, 
ceases not, and its morbid entity is constituted 
by the succession of symptoms which alone 
vary in intensity and duration. 



General Observations. 7 

There may be remissions of fever, but there 
is never an} r arrest or intermittency in the 
course of the disease. There may be relapses 
from imprudence, or from a new growth of the 
bacillus icteroides, but once the disease is 
declared and active, it terminates only in recov- 
ery or in death. 

It is an affection of one paroxysm. 



CHAPTER II. 



SYMPTOMATOLOGY. 



For the sake of clearness of exposition, the 
symptoms of Yellow Fever can be divided as 
follows : 

i. Symptoms of invasion. 

2. Symptoms of the disease proper. 

3. Symptoms of termination. 

In the first two periods the symptoms, more 
or less pronounced, are about the same in the 
light cases as well as in the serious or dan- 
gerous ones. 

Symptoms of Invasion. 

In seventy-five to eighty per cent, of the 
cases, the patient, while in full health, is seized 
with a severe chill over the whole surface, last- 
ing fifteen to twenty minutes ; then an intense, 
scorching heat ; congestion of the head, very 
painful ; of the face, glossy and florid ; of the 
eyes, shining and injected ; of the mucous mem- 



Symptomatology. 9 

brane of the nose, epistaxis at times ; of the 
skin, very red, burning and dry ; of the liver, 
increase in volume ; of the stomach, nausea, 
vomiting ; of the kidneys, urine dense, scanty, 
febrile ; of the uterus, often a bloody flow. 

Cephalalgia is wearisome, oppressive, over- 
whelming ; rachialgia is very acute, lancin- 
ating ; aching of the limbs ; general soreness ; 
malaise ; cardiac, respiratory, and cerebral un- 
easiness ; burning thirst, and, according to 
temperament : in the plethoric, intolerable 
pains in the head and in the back ; in the 
nervous and the alcoholic, incessant vomiting, 
agitation, delirium. 

Temperature at the outset : in light cases, 
102 deg. to 103 deg. F. ; in moderate cases, 103 
deg. to 104 deg.; in grave cases, 104 deg. 
to 105 deg. However, even light cases often 
show at the outset a temperature of 104 deg. 
and above. 

Pulse: in children and adolescents, 130 to 
140 pulsations; in adults, 120 to 130. In 
Yellow Fever, the pulse at the outset is strong, 
full, vibrating. 

These figures naturally are given as average 
ones ; for, it is unnecessary to say, Yellow 
Fever is not always the same, with the same 



io Yellow Fever. 

symptoms marked in the same manner ; the 
type of the fever varies according to the tem- 
perament and the organism ; in more than two 
thousand cases of Yellow Fever, treated during 
the course of nine epidemics, I have never met 
tw r o alike. 

The first period is specially characterized by 
an intense congestion of all the organs save the 
lungs, which nearly always remain unaffected. 

The icteroid toxin paralyzes all the capillary 
vessels. It is in the capillaries that Sanarelli 
has chiefly found the pathogenic microbe. 

The capillaries dilate, become engorged, and 
this general congestion is what characterizes 
particularh' the outset of Yellow Fever. 

Symptoms of Disease Proper. 

The symptoms of congestion last from forty- 
eight to seventy-two hours ; less if the treat- 
ment has been well managed. 

At the end of the second dav, the cerebral 
congestion and the cephalalgia diminish, the 
head yet remaining heavy and painful during 
forty-eight hours ; the acuteness of the pain, 
however, diminishes at the end of twenty-four 
hours, or earlier. 



Symptomatology. i i 

Often, even at the ontset of the disease, the 
skin becomes covered with perspiration, which 
is a very good sign, if the sweating is not very 
profuse. A few patients go through the dis- 
ease with the skin always moist, and they 
usually recover. 

Vomiting persists twenty-four to thirty-six 
hours in children, in nervous women, and 
especially in the alcoholic, if the stomach is 
not given the most absolute and complete rest. 

The redness of the skin disappears on the 
second day, when the latter takes on an earthy 
and wilted appearance. The eyes are also no 
longer congested, and show, in the interior of 
the small superficial vessels, a slight dirty- 
yellow tint, not to be confounded with the 
icteroid suffusion of the sclerotic, which rarely 
appears before the end of the third day. 

The urine in light cases never contains 
albumin and becomes more abundant on the 
second and the third day. In the cases of mod- 
erate intensity albumin appears on the second 
or third day, to the extent of ten or fifteen per 
cent. ; in the grave cases, with high temperature, 
albumin is detected after fifteen or twenty-four 
hours, and increases daily with the gravity of 
the disease. The quantity varies, however, 



12 Yellow Fever. 

reaching ten, twenty, fifty, and even seventy- 
five per cent. 

The temperature falls, in the light cases, 
defervescence being accomplished in a regular 
manner. In the moderate cases the fever 
shows during two, three, even up to five days, 
light remissions in the morning, and slight 
exacerbations at night. In the grave cases, 
the temperature is at the outset, or soon reaches 

104 deg. and 105 deg. It remains during the 
first two days constantly between 104 deg. and 

105 deg. 

The pulse decreases always, at the time of 
each visit, in all cases of Yellow Fever. If it 
does not decrease, which is the rule, it remains 
stationary, which is the exception, the temper- 
ature rising at the same time by one to three 
or even four degrees. 

Symptoms of Termination. 

When the patient is to recover, all the 
symptoms improve, vomiting ceases, the pains 
disappear, the urine increases in quantity, al- 
bumin diminishes or disappears ; the fever, on 
the fourth and fifth days, falls continuously 
and regularly. In the moderate cases, defer- 



Symptomatology. 13 

vescence occurs step by step, elevation of fever 
at night, remission in the morning, until the 
sixth or seventh day, when the temperature 
becomes normal or even subnormal. 

Sleep returns ; the appetite awakens, becom- 
ing at times voracious ; beware of satisfying it. 
And the disease is blotted out, disappears little 
by little, silently, leaving behind only a slight 
icterus in the light cases, pronounced in the 
moderate. 

All danger is past. There remains only a 
great weakness and a slowing pulse, which 
always becomes slower and slower, even dur- 
ing the first days of a well established con- 
valescence. 

At times, toward the end. of the disease, pro- 
fuse and critical cold sweats accompany an 
alarming state of collapse, which, however, 
passes away rapidly upon appropriate treat- 
ment — horizontal position, lowering of the 
head ; some hot black coffee, aromatized with 
a tablespoonful of rum or of whiskey, and fric- 
tions with spirits of camphor or hot vinegar. 

In the grave cases, icterus appears at the 
beginning or the end of the third day ; the 
sclerotics are slightly suffused ; thence, it in- 
volves the face and all the body, increasing in 



14 Yellow Fever. 

intensity toward the fourth day, changing from 
a pale to a light yellow, a bright yellow, a 
greenish yellow, a mahogany yellow. 

The gums, at the beginning of the third 
day, appear swollen, tumefied, of a wine col- 
ored or leaden hue. The slightest pressure 
starts them to bleed ; on the fourth day, and on 
the following days hemorrhage from the gums 
continues. 

The eyes become hollowed and assume an 
expression of heartrending sadness, or of wild 
fright. 

The fades is changed, the nose is pinched 
and bleeds also. 

The stomach, tender on pressure, contracts 
from time to time to eject a black liquid mat- 
ter full of stringy mucus, and from which set- 
tles digested blood resembling a strong infusion 
of parched coffee (coffee grounds). At times 
the blood is almost pure and in large quantity. 
At others the vomit consists of thick mucosi- 
ties, dotted with dark spots resembling chopped- 
up fly wings. 

Epigastric and abdominal pains cause the 
patient to cry out. The stools are black, 
bloody, very frequent, and of a cadaveric odor. 
The urine is suppressed, or very scanty, a few 



Symptomatology. 15 

spoonfuls, or a few drops, in twenty-four hours. 
Upon heating, the entire urine thickens and 
forms a coagulum. 

All the mucous membranes ma}' bleed. 

The temperature falls rapidly, perpendicu- 
larly on the chart, falling 8 to 10 deg., down to 
96 or 95 deg. 

The pulse becomes faint, thready, and can 
not be counted. 

Cold, clammy^ sweats. 

Petechise, ecchymoses in large patches. 

Often coirvulsions ; subsultus tendinum ; hic- 
cough, which is very painful and persistent ; 
coma ; and finally death, which puts an end to 
the tortures of the patient. 

No other disease presents such a heartrend- 
ing, poignant, and terrifying finale as Yellow 
Fever, rnainly because it kills the young. 

Death due to an overwhelming infection by 
the icteroid toxin is produced by the profound 
alteration of the blood ; by the fatty degeneration 
of the. liver, of the kidneys, of the heart, of the 
capillary blood vessels ; and by hemorrhage of 
the mucous membranes of the nose, the mouth, 
the stomach, the intestines, and the womb. 

Everything was congested at the outset, 
everything bleeds at the end ! 



1 6 Yellow Fever. 

A mixed infection acts mostly on the kid- 
neys, hence the patient dies, nearly always 
vomiting black, it is trne, but from the uremic 
accidents : respiratory interference, suppression 
of urine, convulsions, and coma, come to the 
front. 

It is, however, very difficult to differentiate 
clinically between the infections, which are 
most often combined. 

The cadaver is always yellow, the tint be- 
coming brighter after death. The dependent 
portions of the body are nearly black, and the 
skin is mottled with ecchymotic patches. 

Has the diagnosis not been made during the 
course of the disease, death presents it in in- 
effaceable and never to be forgotten characters. 

Nothing is more difficult than to describe 
and expose in a clear and succinct manner all 
the symptoms of Yellow Fever, which offer so 
many variations, in intensity mainly, according 
to whether it be benign, grave or fatal. 

I shall take up again the principal symp- 
toms, bringing them out in relief according to 
their importance, in order to enlighten the 
diagnosis, facilitate the prognosis, and guide 
the treatment. 

This will be the chief object of my labors. 



Symptomatology. 17 

I shall, with the aid of numerous clinical 
observations, thoroughly study the curves of 
the temperature and of the pulse, which fur- 
nish within the first seYenty-two hours the 
pathognomonic diagnostic signs of Yellow 
Fever. 

Fulminating Invasion. 

Yellow Fever in seventy-five per cent, of the 
cases strikes like lightning. On September 7, 
1866, having made numerous visits in the 
morning and breakfasted with excellent appe- 
tite, I was suddenly taken with an intense, nay, 
an icy chill, which led me to believe that my 
last moment had come. Taking my tempera- 
ture, I found it to be 104 deg. 

In 1867, I was called to a butcher, aged 56, 
and an alcoholic, who, otherwise in good health, 
had been taken at the French Market with 
such an intense chill that he had fallen to the 
pavement ; I saw him twenty minutes after the 
initial chill, his temperature was 105 deg. 

In the other twenty-five per cent, of the 
cases, the disease is ushered with less of a 
crash : a few hours of malaise ; light chills ; 
sensation of cold in the feet and along the spinal 
column ; then fever, nausea, vomiting. 



1 8 Yellow Fever. 



Cephalalgia. 



Cephalalgia always exists and is acute, 
crushing, lancinating. In the plethoric with 
high fever, it overwhelms and throws the 
patient into an agitated somnolence. 

This headache, which is supra and infra- 
orbital, is of a throbbing character through the 
cranium, and has exacerbations provoked by 
the least movement, and especially by vomit- 
ing or retching. " My head is bursting," says 
the patient. The congested and sensitive eyes 
can not bear the light ; the acuteness of the 
cephalalgia lasts from fifteen to twenty hours. 

Rachialgia. 

The pains are more intense and exacerbat- 
ing throughout the region of the kidneys. 
They are comparable to severe lashes across 
the back ; to pointed, red-hot irons sunk into 
the flesh ; to blows with a club, sufficient 
to break the bones. 

The patient, when the nausea or the vomit- 
ing allows a moment of respite, has strength 
only to utter the continuous lamentation : "Oh ! 
my head ! Oh! my back!" 



Symptomatology. 19 

Nausea and Vomiting. 

Nausea and vomiting begin immediately at 
the outset of the disease, especially if the 
stomach is full. My breakfast of 1866 did not 
remain in my stomach five' minutes. 

The vomited matter consists of food, bile, 
mucus. Vomiting indicates gravity when it is 
incoercible and lasts more than twenty-four 
hours. When the stomach is empty, the 
spasmodic contractions are much more painful, 
and the suffering in the epigastrium to a 
marked degree depresses the patient, on whom 
the perspiration rolls down in large drops. 

While this spasmodic state of the organ 
lasts, the stomach tolerates no medication ; the 
latter is rejected as soon as taken. The pains 
produced by the nausea and vomiting fatigue 
the patient to a pronounced extent. They 
usually last from twelve to twenty hours ; their 
intensity is influenced by the nervous condition, 
anterior lesions of the organ, and especially 
hy the elevation of the temperature. 

The initial chill in full health ; the sudden 
outset of a high fever ; the rapid congestion 
of all the organs ; the cephalalgia ; the rachial- 
gia ; the vomiting, form a group of symptoms 



20 Yellow Fever. 

which should always cause us to suspect this 
disease iu a city where there has already beeu, 
or may yet be, or where there perhaps is Yel- 
low Fever. If the epidemic, is already de- 
clared, the suspicion turns into certainty. 

However, a positive clinical diagnosis can be 
established only by careful observations of the 
pulse and the temperature. 

Hemorrhage. 

There are symptoms in Yellow Fever which 
give rise to a different interpretation as to 
gravity, according to the period at which they 
occur. 

From the fact that an erroneous interpreta- 
tion ma^' give rise to fears of a danger which 
does not yet exist, we must always bear in mind 
the exact day and hour of the outset of the 
disease, and know thoroughly, as well, on 
which day of the disease such and such a 
symptom ordinarily appears. 

For prognostic purposes, especially, there are 
in Yellow Fever two kinds of albuminuria and 
two kinds of hemorrhage — albuminuria or 
hemorrhage from congestion, albuminuria or 
hemorrhage from infection. Hemorrhage of 



S YM PTOM ATOI.OG Y . 2 1 

congestion is epis taxis, in both sexes, and 
metrorrhagia in yonng girls and yonng women. 
These symptoms at the ontset, like the mod- 
erate perspiration, are most frequently favora- 
ble. They act as a safety-valve, but epistaxis 
may give rise to an error of judgment against 
which one must guard. Sometimes bleeding at 
the nose may occur five or six hours after the 
outset of the disease, during the period of the 
most active congestion. Owing to intense 
cephalalgia, the patient remains on his back ; 
the blood, not flowing completely from the 
anterior nares, runs down the posterior nares, is 
swallowed into the stomach, and the same day 
or the morrow, even on the third day, as I 
once observed, black vomit occurs. Anxiety 
is produced, a grave symptom is thought to 
have occurred. In order correctly to appreciate 
the prognostic value of this vomiting, it must 
be remembered that true infectious black 
vomit very rarely occurs before the third day, 
and that, most frequently, it occurs on the 
third day only in the excessively virulent 
cases. It is mainly on the fourth and fifth 
day that it is noticed. 

I have seen, once only, black vomit appear- 
ing at the end of thirty-six hours. It was in 



22 Yellow Fever. 

the case of the butcher of whom I have 
already spoken. Four or five hours after the 
initial chill, his urine contained fifty per cent, 
of albumin, and he died forty-two hours after 
the seizure. His was the most acute case I 
have ever seen, but he was fifty-six years old 
and an alcoholic. 

Therefore, knowing the exact hour of the 
outset of Yellow Fever, should black vomit 
occur on the first or second day, you may be 
reassured and certify that the blood does not 
come from the stomach, but from the nose ; 
you can also certify to it on the third day as 
well, unless the general condition be exces- 
sively bad. 

Epistaxis is likely to occur especially in 
children and adolescents, and I consider it as 
of good augury, particularly if it be of short 
duration and does not recur. 

Hemorrhage from the gums is a symptom 
almost contemporaneous with true black 
vomit, hemorrhage from the stomach. It, 
however, at times precedes the latter by twelve 
hours ; but the tumefaction and the bleeding 
of the gums are grave symptoms, precursory 
of black vomit. 

You must be on your guard also when you 



Symptomatology. 23 

see blood in the mouth on the first or second 
day. This blood may come from the nose or 
from an alveolar hemorrhage, following the 
extraction of a tooth one or two days previous. 
I have observed two such cases. If the gum 
itself bleeds, you can, by careful examination, 
see the blood ooze. The gums rarely bleed on 
the first or the second day. 

Bleeding of the gums, black vomit on the 
third and fourth day ; sanguinolent extravasa- 
tions in the cellular tissues on the fifth and 
sixth day or earlier, always indicate a dangerous 
virulence of the disease. These hemorrhages 
are always accompanied by icterus, a fall of 
temperature, and a feeble, thready pulse, which 
can not be counted. 

If the patient is young, not an acoholic and, 
especially, if he continues to urinate, even very 
scantily, all hope of recovery is not to be lost. 

Black vomit occurring on the third day and 
even on the fourth is nearly always fatal. It 
is always a very alarming symptom, but the 
later it appears, the less bad the prognosis. 
The recurrence of black vomit is very signifi- 
cant ; some patients having black vomit once 
or twice recover. Occurring in children and in 
young women black vomit is certainly of less 



24 Yellow Fkvkr. 

gravity. In 1878, of the eleven children among 
my clientele who had black vomit only two 
died. 

Icterus. 

Icterus is nearly always of biliary origin, 
but Sanarelli believes that in the cases in 
which the reaction for Biliary pigments is not 
obtained in the urine, 'the characteristic straw- 
colored pigmentation of the skin must be due 
to an ulterior oxidation product of the coloring 
matter of the blood impregnating the tissues. 
In such cases the icterus would be hematic in 
character. 

Icterus first appears in the conjunctiva ; a 
light yellow suffusion shows itself in the grave 
cases at the beginning of the third day, in- 
creasing in intensity day by day, reaching 
the face, then the entire surface of the skin. 
We must not mistake for icterus on the first 
two days the dirty yellow color noticed in the 
capillaries of the conjunctiva, which is only a 
relic of the active congestion of the outset, a 
fatty degeneration of the endothelial cells. The 
icterus varies greatly in intensity and appears 
in nearly all cases, since it is from this symptom 
that the disease has been named. The yellow 



Symptomatology. 

is of ten light and lemon-like ; of the most grave 
prognostic sign is the greenish yellow, the 
mahogany yellow, the4atter nearly always fatal, 
especially if it appears on the third day 
together with black vomit. 

The icterus indicates the degree of lesion of 
the hepatic cell. Sometimes on the sixth or 
seventh day it becomes very intense, unaccom- 
panied by black vomit, the nrine remaining 
abnndant though albuminous, and the patient 
recovers. I have often wondered if in these 
cases there was always a fatty change in the 
hepatic cell, and if sometimes the icterus was 
not produced by fright and by a reflex contrac- 
tion of the biliary ducts such as in cases of 
pronounced emotional jaundice. 

We must never weigh the meaning of the 
jaundice alone, a fact holding good with the 
other symptoms of Yellow Fever. 

The general rule is the later and lighter the 
jaundice the less serious the disease. 

The Urine and Albuminuria. 

The physician attending a patient ill with 
Yellow Fever must never lose sight either of 
the general condition — that is, of the symp- 



26 Yei^ow Fever. 

tomatic ensemble, which is of prime impor- 
tance, nor of the functional condition of the 
stomach or of the kidneys, or of the degree of 
temperature. 

During the entire course of the disease the 
urine must be investigated, measured, analyzed. 
The quantity of urine voided in the twenty- 
four hours must be noted daily. The urinary 
secretion must be just as carefully and minute- 
ly observed as the pulse and the temperature. 
In Yellow Fever the night glass may yield just 
as useful indications as the watch and the 
thermometer. 

The kidneys play an important part in 
Yellow Fever. As in all infectious diseases, 
the toxins are eliminated chiefly by the kid- 
neys, and any lesions produced in those organs 
by the toxins which may modify, diminish, or 
arrest secretion, contribute even more than 
black vomit toward a fatal termination. 

It is exceedingly rare that a patient voiding 
a pint or more of urine daily should die of 
Yellow Fever. 

From the standpoint of prognosis, it is most 
important to know the amount of urine voided 
in twenty-four hours. The quantity is more 
important than the quality. 



Symptomatology. 27 

A medium amount of excretion, beyond one 
pint on an average, is favorable ; an abundant 
qnantity is a sign of recovery ; very abundant, 
two to three pints, means the certainty of a 
happy termination. Scanty urine — grave prog- 
nosis , anuria — death. 

The urine in Yellow Fever is always acid, 
very acid. When it contains bile it has the 
characteristic color. 

It sometimes happens that urine is secreted 
but that a pseudo-paralysis of the bladder pre- 
vents the voiding of it. Twelve hours should 
never be allowed to elapse without catheteriz- 
ing the patient if he has not urinated. Fre- 
quently, three-quarters of a pint of urine may 
be drawn. Even in very grave cases, cathete- 
rize. If you find the bladder empty, your 
prognosis will be enlightened ; and if you find 
it full, all hope will not yet be lost. 

The quantity of urine voided in twenty-four 
hours, and the amount of albumin it contains, 
are the best guides to the anatomo-pathologic 
condition of the kidneys. Nephritis is con- 
secutive to the icteroid intoxication and, accord- 
ing to the magnificent experiments of Sanarelli 
on animals, the renal parenchyma is always, 



28 Yellow Fever. 

next to the hepatic parenchyma, the most 
seriously affected by the specific toxin. 

From the clinical standpoint, there are in 
Yellow Fever congestive and infectious albu- 
minuria, just as we have congestive or infec- 
tious hemorrhages. 

When the fever is very high at the outset 
of the disease, between 104 deg. and 105 deg., 
and the symptoms of congestion are very 
pronounced, the urine contains at the first or 
second analysis, on the first or second day, from 
five to fifteen per cent, of albumin. This albu- 
minuria indicates a serious condition only if 
the fever and the congestive symptoms do not 
yield. Frequently, at the end of forty-eight 
hours, the temperature having lowered and the 
congestion diminished, albuminuria diminishes 
or disappears. This form of albuminuria, of fre- 
quent occurrence in such cases, is due to conges- 
tion, to a passing glomerulitis which is noticed 
in many other infections with high fever. In the 
serious cases, however, to this congestive albu- 
minuria is soon added an infectious albuminu- 
ria, which is produced by lesions of the paren- 
chyma ; fatty degeneration, alteration in the 
capillaries, blocking up of the tubules by 
epithelial and hyaline casts. According to 



Symptomatology. 29 

Sanarelli, who has investigated all these lesions 
with a master mind, the glomeruli present 
some vessels denuded of epithelium, and there 
are interstitial hemorrhages. 

The amount of albumin increases on the 
third or fourth day, and can reach thirty to 
fifty per cent, and more. The scantier the 
urine, the more albuminous it is. 

During the epidemic of 1897 I saw > m con " 
sultation, a girl of fourteen on the third day of 
an apparently mild attack of Yellow Fever. 
Her urine, though copious, contained a large 
proportion of albumin, fully fifty per cent.; the 
next day there was seventy-five per cent., the 
other symptoms presenting no gravity and 
giving no explanation of this anomaly. Upon 
questioning the family, we learned that this 
child had at the age of nine been treated by 
me for a severe case of scarlatina. She had 
recovered completely from the scarlatina, but 
evidently her kidneys had been damaged by 
the scarlatinal toxin and the icteroid toxin, 
adding its effects to those of the anterior lesion, 
explained this excessive albuminuria. The 
patient made a perfect recovery, the albumin 
disappeared, but I am convinced that renal 
lesions remained and are likely to develop 



30 Yellow Fever. 

slowly and to compromise her health, at some 
future date. She will be subject to renal 
troubles. 

This fact is cited to demonstrate how impor- 
tant it is to know the past pathological con- 
dition of a patient attacked by Yellow Fever. 

Pulse and Temperature. 

The sudden outset, the chill, the fever, the 
congestion of all the organs, the cephalalgia, the 
rachialgia, the icterus and black vomit, when 
grouped, characterize icteroid typhus, but each 
one of these symptoms is met with separately 
in other infectious diseases. 

The symptom which alone best characterizes 
Yellow Fever, and which has been observed in 
New Orleans ninety-nine times in a hundred, 
and which is not found at the outset of any 
other febrile affection, is the progressive fall 

OF THE PULSE RATE. 

This fall of the pulse consists in the fact 
that at a given visit you do not find the same 
number of pulsations which you had counted 
at the preceding ones. 

During the first three days of Yellow Fever, 
each time the pulse is taken a smaller number 
of pulsations is noted. 



Symptomatology. 31 

The pulse rate is falling. 

If at your first visit you have noticed one 
hundred and twenty pulsations, you will have 
one hundred and ten at your second, one hun- 
dred at the third, ninety at the fourth, and so 
on, with more or less regularity during the 
first three days of the disease. 

At times, the number of pulsations remain 
the same during twelve or twenty-four hours 
if the fever is very high, or if the fever 
rises, especially in children, in nervous people, 
and in the alcoholic, but the lowering of the 
pulse occurs later, is accentuated, and becomes 
as characteristic as if there had been no 
arrest in the fall. Notwithstanding slight 
variations, the progressive fall of the pulse in 
Yellow Fever is, during the first seventy-two 
hours, an almost absolutely pathognomonic 
law. In over two thousand cases of Yellow 
Fever which I have treated, I have nearly 
always observed it. 

Naturally, in order to obtain a correct ob- 
servation of the pulse, it must not be counted 
just as the patient has risen or moved about 
actively, or has made efforts at vomiting. The 
patient must have been lying down and at rest 
during eight to ten minutes. Under such cir- 



32 Yellow Fever. 

cumstances you will be able to observe the fall 
in the pulse rate during the first three days. All 
physicians know that the pulse does not beat 
at the same rate whether the patient is lying, 
sitting, or standing. 

It is also necessary to allow sufficient time 
for the patient to recover from the nerv- 
ous impression and the acceleration in the 
heart's action often produced by the physi- 
cian's visit. The medical pulse, especially in 
nervous subjects, is not the true pulse. 

This fall in the pulse rate had been noticed 
by physicians of the last century and of the 
beginning of this century, who had treated 
Yellow Fever in the West Indies, in New York 
and in Philadelphia, but not one of them had 
understood its importance and brought out its 
diagnostic value, so that this constant and typi- 
cal phenomenon has not obtained a marked 
position along with icterus and black vomit. 

Upon reading Yellow Fever observations of 
that time, if the pulse has been counted at each 
visit, a manifest fall of the pulse rate is always 
noted. Delmas, in his treatise on Yellow Fever, 
1822, describes the phenomenon perfectly, hav- 
ing observed it without, however, having gen- 



Symptomatology. 33 

eralized it or drawn from it any practical con- 
clusions. 

To Dr. Charles Faget, a very distinguished 
physician of New Orleans, is due all the honor 
of having studied the course of the pulse and 
having promulgated the law of its fall in Yel- 
low Fever. 

After the epidemics of 1853, 1858, 1867, 1870, 
1873, he called attention to the importance of 
the study on the part of physicians of the 
pulse in Yellow Fever ; by the lucidity of his 
teaching and the large number of his published 
observations he made of the fall in the pulse 
rate during the first days of the disease one of 
the indispensable diagnostic signs. 

This phenomenon, which is met with only in 
Yellow Fever, should never be forgotten by 
physicians during epidemics. 

In all febrile infectious diseases the pulse 
and the temperature are always in correlation ; 
if the fever rises, the pulse rate increases ; if 
the temperature diminishes, the pulse rate 
falls ; hence another phenomenon still more 
forcible and demonstrative than that just men- 
tioned is that, in Yellow Fever, the tempera- 
ture often rises one. to four degrees, even while 
the pulse continues to fall. 



34 Yellow Fever. 

It is this divergence between the falling 
pulse rate and the rising temperature which is 
Faget's law, a wonderful law, unfortunately 
little known, and which, in the congestive 
period of the disease, is the pathognomonic diag- 
nostic sign of Yellow Fever, just as character- 
istic as are icterus and black vomit during the 
period of infection. 

Upon coming to New Orleans to practise 
medicine in 1865, I had a clinical thermome- 
ter in my baggage. I believe that I am one of 
the first physicians in the United States to 
have utilized this precious instrument in the 
diagnosis of fevers. I am sure I was the first 
in Xew Orleans to have used it for the study 
of the march of temperature in Yellow Fever 
during the epidemics of 1866, 1867 and the 
following ones. Hence, I was one of the first 
to note this divergence between the pulse and 
the temperature in Yellow Fever ; but it is Dr. 
Faget who, with his observations and mine, 
built up the magnificent law which bears his 
name in all justice, as it is he who first caused 
it to be known to the medical public by his 
remarkable treatise, " Monograph ie sitr le type 
et la specificite de la Fi&vre Jaune, etablis 
avec V aide de la nwntre et du thermometre^' 



Symptomatology. 35 

which is a masterpiece of originality and of 
science and judgment. 

It is now over twenty-five years since this 
law has been promulgated ; yet, notwithstand- 
ing the fact that it remains unshaken, and 
that its importance and value are of the high- 
est order in enabling the making of a positive 
diagnosis on the first or second da}', it is yet 
very little known ; in the numerous works 
which have been published within twenty-five 
years, it is mentioned, but it does not occupy 
the place it deserves, and is yet completely 
ignored by some physicians who treat Yellow 
Fever. I shall try to demonstrate again, with 
the assistance of clinical charts of the pulse 
and the temperature, the importance of the 
fall in pulse rate and the lack of correlation 
between the pulse and temperature as aids to 
an early and positive diagnosis of Yellow 
Fever. 

This is a nail requiring to be driven into 
the medical head. 



CHAPTER III. 



FALL IN THE PULSE RATE— FAGET'S LAW- 
CLINICAL CHARTS OF THE PULSE AND 
TEMPERATURE — TYPES AND VARIA- 
TIONS OF YELLOW FEVER. 



Observations. 

The charts of the pulse and temperature 
which I shall pass under the reader's eye, whilst 
commenting upon and explaining them, have 
been selected as the most typical among sev- 
eral hundred complete observations which I 
collected during nine epidemics in my private 
practice and at the Hospital of the French 
Benevolent Society of New Orleans, whose 
physician in chief I was during twenty years. 

In order that the physician may draw from 
these curves the most profitable teaching, I 
shall, in their exposition, begin by the mildest 
cases, showing, as we go, the variations which 
can be observed; we will follow with the cases 
of average intensity, with the grave ones, the 
very grave, and the fatal. 

36 



Pulse Rate — Faget's Law — Charts. 37 

This collection of pictures will include the 
different types of Yellow Fever observed by 
me, the most frequent as well as the most rare ; 
they will show also that, just as the symptoms 
of Yellow Fever vary ordinarily only in inten- 
sity, so do the curves of the pulse and the 
temperature retain, even in their numerous 
variations, a family air, an easily recognized 
physiognomy, one especially difficult to con- 
found with the clinical curves of any other 
febrile infectious disease. 

In studying and comparing these curves, the 
physician will have, I hope, a clean cut and clear 
idea of Yellow Fever; he will be able to make a 
good diagnosis within the first thirty-six hours, 
at the beginning of an epidemic, even if he 
has never previously seen a case of it, knowing 
its symptoms, so characteristic at the outset, 
and knowing their succession and, especially, 
the fall in the pulse rate and the typical lack 
of correlation between the temperature and the 
pulse. 

The course of the temperature, the height of 
the fever, its exacerbations and remissions, 
indicate, during the first three days, much bet- 
ter than any other symptom what is likely to 
be the termination. 



38 Yellow Fever. 

Especially during the first three days, the 
temperature must be the physician's autocratic 
guide in the treatment. 

Temperature and virulence are most often 
united, whether the temperature rises in the 
period of congestion, or whether it falls in the 
period of infection. 

In these clinical notes I have often used the 
two expressions, period of congestion and pe- 
riod of infection, in order to render as clear as 
possible the symptomatic exposition of the dis- 
ease ; but it must be well understood that the 
pathogenic element, the bacillus icteroides and 
its toxin, is the same in both periods. 

In the congestive period the organism is 
battling with intense reaction against the in- 
vader and its poison ; in the infectious period, 
the germ has already produced cellular lesions 
and functional troubles. 

The period of congestion is the battle, which 
ordinarily lasts three days ; the period of in- 
fection is that of defeat, but the organism, 
although wounded, is not yet hors de combat, 
and even in the most grave cases, can yet re- 
trieve its fortunes. 

In order to be a useful ally to our patient 
we must never forget to count the pulse and 



Pulse Rate — Paget' s Uw — Charts. 39 

to take the temperature twice a day — in the 
mouth for adults, in the rectum with children. 
Let each patient have his thermometer. 

I believe it important to say once more, as 
my charts prove it, that the fall of the pulse, 
which is so constant, so useful in the diagnosis, 
is a phenomenon of the period of congestion, 
of the first three days of the disease. 

Sometimes this fall continues during the 
entire disease, especially in the light cases, in 
those of medium intensity, and even in the 
very grave ones, but the general rule is that it 
ceases after the third day. 

The variations of the pulse without being 
very accentuated are then very manifest after 
the third day. The number of pulsations 
is not as high as at the outset, but the pulse 
is variable, for it no longer is influenced 
only by the icteroid toxin. On the third day 
the organic situation is no longer the same. 
The toxin has produced cellular lesions ; fatty 
degeneration ; the kidneys, the liver, and the 
stomach are affected and their functions are no 
longer properly carried out or are entirely 
arrested. 

Other microbes, the streptococcus, the colon 
bacillus especially, the proteus, and so forth, 



40 Yellow Fever. 

finding a good culture medium, add their toxins 
to the yellow toxin and create secondary 
infections. 

The urinary purification not being carried 
on properly, the liver no longer destro3 T ing the 
toxins of the intestines and the ptomains, 
the organic poisons accumulate and create an 
auto-infection which becomes added to the 
infection of the icteroid toxin and that of the 
other microbes. 

The infection has now become mixed and 
the icteroid toxin no longer reigns alone in 
the organism as during the first three days of 
the disease. 

It is certainly these secondary infections and 
auto-infection which modify the pulse and 
render it variable, for in the cases of pure Yellow 
Fever, without pronounced nephritis, with 
abundant urine, the progressive fall of the 
pulse rate continues until death. 

The fall of the pulse, then, is most partic- 
ularly a symptom of the first three days, and 
this is one of the facts confirming the im- 
portance which I claim for the knowledge of 
the exact hour of the beginning of the disease. 

In the observations which accompany my 
clinical charts I shall give only the interesting 



Pulse Rate — Faget's Law — Charts. 41 

details of the disease, not forgetting that it is 
chiefly the fall in the pnlse and the divergence 
between the pnlse and the temperature which 
I desire to demonstrate. 

I shall publish a few complete observations, 
illustrating typical cases only, not desiring to 
load this w r ork with details fastidious in their 
repetition and remembering that this clinical 
monograph is to be read chiefly by physicians. 



Type: Mild Yellow Fever. 
Xo- 1— September, 1878. ]STo. 2— Sept. and Oct., 1897. 



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Recovery. 



Recovery 



Pulse Rate — Faget's Law — Charts. 43 

Observations Xos. i and 2. 

In these charts, the dotted lines indicate the 
curves of the temperature, the straight lines those of 
the pulse. The first line of figures gives the date of 
the month, the second, the day of the disease. 

Clinical Charts Xos. 1 and 2, are charts of the 
very light Yellow Fever of children and of ado- 
lescents. It is the form which is observed at least 
seventy-five times in a hundred in the Yellow Fever 
of children, fifty times in a hundred in adolescents, 
and twenty-five times in adults, who are perfectly 
sound and without organic taints. This is what is 
called acclimating fever, and which I call a caress 
bestowed by Yellow Fever. Even such a benign 
attack gives immunity to the patient, vaccinates and 
protects him against an}' further attacks. 

No. 1 was a child aged 6 years; Xo. 2 an adolescent 
17 years old. 

In both cases the disease began, the patient being 
in full health, by a chill, congestion of the face, 
intense cephalalgia, very painful rachialgia, the vom- 
iting of aliments, in the child whose case is recorded 
in Chart Xo. 1, it having been taken sick right after 
supper, and nausea only in patient Xo, 2 ; light 
epistaxis. 

The fever at the outset was very high, reaching 
nearly 105 deg. in Xo. 1. The progressive fall in the 
pulse goes on without interruption, the number of 
pulsations and the temperature falling continuously, 
giving us parallel lines on the chart. The fall and 
defervescence are in perfect harmony. The pulse of 
patient Xo. 2 fell to 50 and he became collapsed and 
almost in a state of syncope. In both cases a light 
icterus was noticeable in the sclerotic. Great weak- 
ness. Xo albuminuria. Duration five and six davs. 
Recovery, 



Type: Mild Yellow Fever. 
No. '•'> -July, 1878. No. i - September, 1878. 



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Pulse Rate — Faget's Law — Charts. 45 

Observations Nos. 3 and 4. 

Adults aged 26 and 21 }'ears, respectively. 

In Charts Nos. 3 and 4 the fall ot the pulse is man- 
ifest from the outset of the disease up to convales- 
cence, but in Case No. 3, on the second and third day, 
the number of pulsations remains stationary during 
twelve hours, but does not increase. This stationary 
condition is sometimes observed when the temperature 
rises, or when it remains stationary at a high degree 
of elevation ; this does not violate the law of the fall 
of the pulse. In Chart No. 4 the fall is progressive 
and without intermission. 

Remarkable points are that in Chart No. 3 the tem- 
perature rises by a degree, while the pulse is lowered 
by five pulsations. In Chart No. 4 the temperature 
rises on the second day nearly two degrees, and on the 
third day two degrees ; yet, notwithstanding this rise 
of fever in two days of nearly four degrees, the pulse 
decreases uninterruptedly by thirty-five pulsations. 

This phenomenon is observed only in Yellow Fever, 
is observed in nearly all the cases and is pathognomo- 
nic. It is this lack of correlation between the pulse 
which falls and the temperature which rises that con- 
stitutes Faget's law. 

Very high fever in Case No. 3, 105 deg. , which is a 
dangerous temperature. In both cases sudden outset ; 
chill ; congestion of the face and eyes ; very intense 
cephalalgia in Case No. 3, with vomiting ; rachialgia ; 
light congestive albuminuria ; light icterus. Dura- 
tion of the disease, six days ; recovery. 



Type: Mild Yellow Fever— Complication, 
ISTo. 5— October, 1897. 



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Recovery. 



Pulse Rate — Faget's Law — Charts. 47 

Observation No. 5. 

This young girl, aged 16, oi a nervous tem- 
perament, but good constitution, was taken sick in 
full health, at four o'clock on the morning of October 
7, 1897; intense chill, violent headache, pronounced 
rachialgia, vomiting, malaise and high fever, face 
much injected, eyes congested and brilliant. 

During the first three days, the fall of the pulse is 
uninterrupted and progressive ; on the first day, not- 
withstanding a rise of .6 of a degree, the pulse is 
lowered by ten pulsations — Faget's law. On the 
second and the third day the pulse and the tempera- 
ture fall in parallel lines. The general condition 
good, stomach quiet, the patient is drinking only 
Vichy water, Celestins, cold, and as much as she 
desires. The urine was very abundant and free of 
albumin so that I considered convalescence as estab- 
lished when, on the night of the third day, the pulse 
and the temperature both rose ; the pulse in twenty- 
four hours by forty pulsations; the temperature 2.7 
deg. I was fearing a recrudescence of the disease 
when the menses appeared and explained the reason 
lor this alarm. 

The menses often show at the outset of the disease, 
even if the period is not due, being produced by a 
uterine congestion with hemorrhage of the same 
nature as in epistaxis. During the outset ot the 
disease, as shown by this observation, this complica- 
tion sometimes causes a rise of temperature. Apart 
from the lever, the general condition was very good. 
Defervescence was uninterrupted and, on the sixth 
day, pulse and temperature were both normal. Pro- 
fuse sweats occurred on the fifth day. Recovery. 



Type: Yellow Fever of Moderate Intensity. 

No. 6— October, 1897. 



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Recovery. 



Pulse Rate — Faget's I^aw — Charts. 49 

Observation No. 6. 

Child 14 years old, nervous, of weak health, taken 
suddenly, while as well as usual, with a chill ; fever; 
prostrating pains in the head, and very acute pains in 
the back ; vomiting ; light delirium. 

Chart No. 6 is remarkable for the uninterrupted and 
progressive fall of the pulse during the first four days. 
The temperature rises one deg. on the second day, the 
pulse losing four pulsations. The third day the fever 
remains stationary and high, 103.5 deg. , the pulse 
falling by twenty-three pulsations. Faget's law is 
well shown. 

The urine remained abundant throughout, but 
became albuminous on the fourth day. 

There were slight variations in the pulse rate and in 
the fever on the fourth, fifth and sixtli days, but, not- 
withstanding a light icterus and a lack of sleep, the 
general state was satisfactory. 

The albumin disappeared on the eighth day, and 
the young man was convalescing after nine days' ill- 
ness. 

On the ninth day a little light solid food caused a rise 
of temperature. This nearly always happens ; solid 
food during convalescence always causes slight fever. 
It is the carnis fever of the ancients. Duration of the 
disease, nine days. Great weakness during fifteen 
days. Recovery. 



Type: Severe Yellow Fever. 
Xo. 7— July. 1878. 



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Recovery. 



Pulse Rate — Faget's Law — Charts. 51 

Observation Xo, 7. 

Male, 30 years old. 

Chart No. 7 is exceedingly remarkable and is unique 
among my observations. It is a pure case, conse- 
quently a good demonstration of the fall in pulse 
rate and especially of Faget's law of lack of correla- 
tion. The fall in the pulse is progressive and unin- 
terrupted during the entire eight days of illness, and 
the pulse falls to forty-six pulsations. 

An extraordinary thing is that the pulse remains 
stationary during twelve hours on the seventh day, 
at eighty-five pulsations, while during the same time 
the temperature rises from 10 1.6 to 105.6 deg. It is 
this enormous divergence between the temperature 
which rises four degrees and the pulse which falls or is 
stationary, as in this case, which is the pathognomo- 
nic diagnostic sign of Yellow Fever. It is Faget's 
law. 

This patient recovered, having had congestive albu- 
minuria and icterus. As a rule, adults whose tem- 
perature during the first two days reaches 105 and still 
more 106 deg., nearly always die. 

I produced defervescence by means of continuous 
cold sponging during several hours, by the adminis- 
tration in abundance of Vichy water and of infusion of 
digitalis: digitalis leaves, fifteen grains; boiling water, 
eight ounces ; tr. of veratrum viride, four drops. 

The feebleness lasted a long time, a proof of the 
virulence of the disease. Recovery. 



Type: Yellow Fever of Medium Intensity. 
No. 8— October, 1870. 



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Kecovpry. 



Pulse Rate — Faget's I^aw — Charts. 53 

Observation No. 8. 

This young man, aged 21, vigorous and rather tem- 
perate, is taken with an intense chill whilst in full 
health; repeated vomiting; severe cephalalgia; rachi- 
algia; general pain; restlessness and uneasiness. 

On the first day the pulse remains stationary at 120, 
the temperature rising one deg.; the fall in pulse rate 
occurs on the second day, a decrease of twenty-three 
pulsations. On the night of the second day the tem- 
perature rises again one deg. to 104 deg., the pulse 
again remaining stationary, after which it falls pro- 
gressively. 

This patient had during two days all the appear- 
ances of a grave attack of Yellow Fever. There was 
15 per cent, of albumin in his urine, and light icterus 
on the fourth day ; he had rather violent delirium on 
the first two nights. Happily the fever did not reach 
beyond 104 deg., and there was a remission of one 
deg. each of the first two mornings. 

When Yellow Fever ranges between 103 and 104 
deg. the patient generally gets well, especially if he 
is not alcoholic. I believe that, notwithstanding his 
denials, this patient must have been drinking a little, 
because he has since become a drunkard. 

The fall in the pulse rate, though with an interrup- 
tion, and Faget's law are characteristically shown. 

The remissions and exacerbations in the fever 
characterize the cases of moderate intensity. The 
pulse line is almost straight in its descent, the tem- 
perature line irregular in its ascent, and the defer- 
vescence is shown by step-ladder lines. Recovery. 



Type: Yellow Fever of Moderate Intensity and Remittent. 

No. 9— August, 1874. 



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Recovery. 



PuivSK Ratk — Faget's Law — Charts. 55 

Observation No. 9. 

Adult, 26 years old. 

In this observation the progressive fall of the pulse 
is typical from the first to the sixth day, notwithstand- 
ing the very accentuated remissions or exacerbations 
of more than two degrees daily during seven days. 

The marked variations of temperature do not mod- 
ify the fall of the pulse, and Faget's law is plainly 
manifest during the first four days. This young man 
was seized, while in good health, with all the symp- 
toms of the outset of Yellow Fever ; vomiting and 
epistaxis at the end of twelve hours, albuminuria 
appeared on the fourth day, though the urine was 
copious, and there was a rather pronounced jaundice 
on the fifth day. 

The temperature, beginning at 101.5 deg., rose 2.5 
deg. on the second day, the pulse, however, falling 
instead ol rising. Defervescence, beginning on the 
third day, was accomplished intermittently and the 
patient became convalescent. 

The fever never surpassed 104 deg. and it ranged 
during six days between 101 and 104 deg., with 
more and more pronounced remissions after the third 
day. A remission of one degree or more is always a 
favorable symptom and announces a recovery, par- 
ticularly if the temperature has not reached 104 deg. 

A dangerous temperature ranges between 104 and 
105 deg., and very grave temperatures reach 105 deg. 
and beyond. It is then that the physician must take 
vigorous action, as I shall indicate in the chapter on 
treatment. Recovery. 



Type: Grave Remittent Yellow Fever. 

Xo. 10— June, 1878. 



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Pulse Rate — Faget's Law — Charts. 57 

Observation No. 10. 

Adult, aged 23 years. 

The outset in this young man's case was quiet. 
Fever light, 102.8 deg., the pulse 100, the congestive 
symptoms very little marked. 

In twenty-four hours the pulse decreased by twenty 
pulsations and the temperature by 2.2 deg., under the 
influence of treatment : sponging, light purgative, 
weak infusion of digitalis and four drops of veratrum 
viride. 

The remedies discontinued, the disease resumed its 
course, the fever rising, beyond that at the outset, to 
104 deg. During three days there were exacerbations 
and remissions of more than one deg. in the morning 
The pulse, which had decreased during the first three 
days, became variable like the temperature without 
tver being in correlation with it ; for 84 pulsations are 
not in proper ratio with 104.3 deg. The patient had 
15 per cent, of albumin in the urine ; icterus on the 
fourth day ; delirium ; and his condition was serious 
without being alarming. 

I publish this observation because it goes to show 
the influence of medication on the temperature. It is 
undeniable, but unfortunately the remedy has no 
action on the microbe and its toxin, hence its effects 
on the fever having passed off, the disease resumes 
its course. All remedies whatsoever given to control 
the fever act badly, be it on the stomach, which they 
irritate, as the sulphate of quinin, or on the kidneys 
whose secretion they diminish, as antipyrin and all 
the antipyretics of the aromatic series. Recover}^. 



Type: Very Grave Yellow Fever. 
No. 11— September, 1S78. 



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Recovery, 



Pulse Rate — Faget's Law — Charts. 59 

Observation No. ii. 

Girl, 23 years of age. 

This clinical chart is rilled with instruction. The 
gravity is manifested by the fever, which ranges dur- 
ing rive days between 104 and 105 deg. The pulse 
of 180 at the outset is of rare frequency and is ex- 
plained by the nervous condition of the girl and her 
fear of dying. This must be taken into account in 
considering the prognosis and must be quieted. The 
temperature even at the outset was very high, 104.6 
deg. , indicating danger. By means of energetic treat- 
ment: a purgative, cold sponging every hall hour and 
digitalis with veratrum viride, the pulse fell to the 
extent of sixty pulsations, and the temperature three 
degrees, in twelve hours. A pulse of 180 is abnormal 
and. in Yellow Fever, every exaggerated symptom 
indicates grave virulence. 

The temperature rose again on the second day to 
104.6 deg. and ranged during four days between 104 
and 105 deg. I had discontinued the digitalis and the 
veratrum : I no longer resort to them because I have 
had repeated evidence that if this medication in- 
fluences the fever, it has no action on the disease, 
whose course is resumed with equal intensity. The 
situation seemed desperate during five days, especially 
when black vomit supervened. The latter stopped 
through absolute rest of the stomach — no medication, 
no drink, no ice. What saved the patient was her 
sound constitution aided by the cold sponging and 
the continuous healthy functioning of her kidneys. 
Intense icterus and 10 per cent, of albumin on the 
fourth day. The pulse remained at 120 during 
twenty-four hours, while the fever rose three degrees 
on the second day. Slight variations on the fourth 
day and the succeeding ones. Recovery. 



Type: Grave Yellow Fever. 
No. 12— September, 1870. 



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Recovery. 



Pulse Rate — Faget's Law — Charts. 6i 

Observation No. 12. 

Adult, aged 23 years. 

The curves in Chart No. 12 are those of grave 
Yellow Fever with remittent type. The patient was 
taken on September 11, 1867, with general aching, 
high fever, severe pains of the head, back and legs. 
I saw him at 10 o'clock ; his skin was hot, red, cov- 
ered with perspiration ; his tongue was coated and 
moist ; his face pale except over the cheek bones, 
where it was red and glossy. Severe supra- orbital 
cephalalgia. 

During three days there are remissions of more 
than one degree in the morning with exacerbations at 
night. The general condition, barring a good deal of 
excitement, remains fair. The urine is abundant, 
although albuminous from the third day. The stom- 
ach acts well; the patient vomited only once, on the 
fourth day, after having taken a purgative. The 
gravity of the case was denoted by the height of the 
fever during five days, above 104 deg. The favor- 
able sign was the morning remission. 

The fever fell uninterruptedly from the sixth to the 
tenth day. Icterus well accentuated on the fourth 
day. Great weakness during one month. 

On the eighth day an ecthymatous pustule formed 
on the right arm, which became highly inflamed from 
the suppuration. According to my experience, the 
formation of pus in Yellow Fever is a good sign. I 
never lost from Yellow Fever a patient in whose body 
pus was being formed. It is probably a coincidence. 
I shall publish two other observations relating there- 
to and shall refer again to this point in the chapter on 
treatment. Recoverv. 



Type: Pure Yellow Fever. Black Vomit. 

NO. 13— SEPTE31BER, 1870. 



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Death, 



Pulse Rate — Faget's Law — Charts. 63 

Observation No. 13. 

Adult, 25 years old. 

A typical case of pure Yellow Fever without pre- 
dominant secondary infections or auto-infection. The 
kidneys acted up to the time of death. The fall in 
the pulse is very noticeable and progressive during five 
days, notwithstanding a rise of nearly three degrees on 
the third day. In this chart the progressive fall in the 
pulse rate and Faget's law are typically apparent. 

First Day — A., 25 years old, a steamship captain, 
noticed a slight malaise on the morning of September 
5, 1870 ; he breakfasted with appetite ; at noon a 
chill, cephalalgia, rachialgia, fever. He is seen at 3 
p. m. ; I find him with a congested and glossy face, 
eyes brilliant, having profuse sweats and burning 
thirst. Has alimentary vomiting. I have him trans- 
ported to land. 

Second Day — Cephalalgia, rachialgia, general ach- 
ing, temperature 106 deg. 

Third Day — Spent bad night, with delirium. Urine 
is abundant, with 10 per cent, of albumin ; face is 
pale ; he is very weak, has vomited a glass of lemonade, 
temperature 105.8 deg. 

Fourth Day — Has had a little sleep and passed a better 
night. Pulse, 78 ; temperature, 103. 1 deg. Urine is 
biliary and ammoniacal. Head is heavy ; has nausea. 
By noon has mucous vomiting, containing black 
specks — coffee grounds. At 3 o'clock, retention of 
urine ; catheterized and two large glasses of thick, 
yellow, ammoniacal and albuminous urine are drawn. 
Vomits all he takes. Speaks little, but asks repeatedly 
if he has Yellow Fever ; is very much worried and says 
he is going to die. The subpalpebral sclerotic slightly 
yellow. By 8 p. m. has black vomit constantly and 
his face is very pale, temperature 104 deg. 

Fifth Day — Sleepless during preceding night, but 
no vomiting and urinates freely. Vomits at 7 A. m,, 



Type: Pure Yellow Fever. Black Vomit. 
No. 13— September, 1870. 





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Pulse Rate — Faget's Law — Charts. 65 

after drinking ; vomited matter contains black particles 
like fly- wings, which sink and adhere to the bottom of 
the bowl. His tongue is moist; pulse, 80; temperature, 
104 deg. Seen at 11 o'clock; his fades is bad; his 
face and body are slightly yellow ; respiration is deep 
and irregular ; urine is free and abundant ; extreme 
agitation. By 8 P. M. his skin is of a deep yellow, al- 
most the color of mahogany. 

Sixth Day — Has passed a very bad and agitated 
night, with slight delirium. Xot having urinated since 
2 p. M. the day previous, he was catheterized and two 
large glasses of urine were drawn. At 3 p. m. passes 
biliary stools and urine. Icterus is very pronounced ; 
skin cadaverous ; pronounced black vomiting. By 6 
p. M. respiration has become shallow and irregular. 
Has a wild expression and constant nausea. 

Seventh Day — Spent a very restless night, with deli- 
rium and hiccough. Skin is of a light mahogany color. 
Large ecchymotic spots on the back and nates ; gums 
swollen and black ; retention of urine ; catheter drew 
half a pint of urine. Death during the night, preceded 
by complete unconsciousness. The cadaver is of a 
mahogany color, mottled with large ecchymoses. 

I have insisted upon the details of this observation 
of Yellow Fever which killed by its own virulence 
alone, without nephritis, without auto-infection. The 
observation is complete and very instructive to such as 
desire to study its curves and classify the symptoms in 
their succession day by day, almost hour by hour. 



Type: Yellow Fever with Acute Nephritis, Black Vomit and Anuria. 

No. 14 — August, 1878. 



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Death. 



Pulse Rate — Faget's Law — Charts. 67 

Observation No. 14. 

Adult, 21 years of age. 

In this case the law of the fall in pulse rate is 
violated, as on the first day the pulse increased twenty 
pulsations instead of falling. 

In this young man of nervous temperament but 
steady habits, the disease commenced by signs of mod- 
erate congestion, but the outset did not forecast the 
fatal issue, though his vomiting was uncontrollable. 

This young man was betrothed and his love affairs 
had interfered with his proper feeding and sleeping for 
several weeks ; excited frame of mind and weakening 
of organic resistance. 

During forty-eight hours the temperature rose like 
a rocket, uninterruptedly to 105.4 c ^ e &- ^ n adults, such 
a temperature is always very dangerous ; notwithstand- 
ing a rise on the second day of two degrees, the pulse 
followed the usual law and decreased by twenty-four 
pulsations. 

Black vomit began on the third da}'. Suppression 
of urine supervened on the fifth day and death ensued. 
The patient was killed by the Yellow Fever toxin and 
particularly the renal lesions and uremia, 

The fall in temperature is always considerable at 
the time that black vomit occurs, but when the 
patient ceases to urinate and vomits black, deferves- 
cence is sudden. In this case it is extraordinarily so, 
the fall being from 105.4 to 95-6 deg. , or nearly ten 
degrees . 

This young man was annihilated by Yellow Fever 
chiefly on account of the incoercible vomiting ; not 
being able to drink he was unable to eliminate the 
toxin. This was in 1878. To-day, new ideas prevail- 
ing concerning infections, chiefly owing to the labors 
of Professor Bouchard, he could be made to drink 
abundantly by the rectal route.. 



Type: Fatal Yellow Fever without Black Vomit. 
No. 15 — September, 1878. 



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Death. 



Pulse Rate — Faget's Law — Charts. 69 

Observation No. 15. 

Girl, 16 years old. 

I had treated, during the first two days of Septem- 
ber, 1878, two sisters of this young girl, who both had 
an attack of Yellow Fever of moderate intensity with- 
out alarming symptoms. 

Her turn came on September 27, when she was taken 
with a fever of 103. 6 deg. ; pulse, 1 40. She was in a state 
of great nervous excitability, speaking only of dying. 
She had frequent vomiting, low delirium and all the 
symptoms of invasion of Yellow Fever. Cold spong- 
ing, digitalis and veratrum lowered the temperature 
nearly two deg. , and the pulse by sixteen pulsations. 
However, on the second da}' the fever rose to 105.2 
deg., remaining at that elevation all day notwith- 
standing a cold bath and cold spongings. There was 
continuous delirium and constant vomiting. She did 
not urinate. Upon catheterization on the second and 
the third day, or during forty-eight hours, I drew the 
first time a teaspoonful and the second time three 
drops of urine. 

On the third day uremic symptoms : uncontrollable 
vomiting ; agitation ; difficult respiration ; delirium ; 
unconsciousness ; extreme pallor. 

She died on the fifth da}' with convulsions, without 
ever having had black vomit. 

Compare the last three observations in order to recol- 
lect how death occurs in Yellow Fever unaccompanied 
by acquired organic lesions : 

No. 13, black vomit, abundant urine. 

No. 14, black vomit, with suppression of urine. 

No. 15, suppression of urine only, and, on the second 
day, without black vomit — a very rare occurrence. 



Type: Pure Yellow Fever. Very Virulent, 
;N"o. 16— September, 1S7S. 



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Death. 



Pulse Rath — Fagkt's Law — Charts. 71 

Observation No. 16. 

This is a case of very virulent Yellow Fever ending 
in death on the seventh day without any secondary 
organic process sufficient to sensibly modify the course 
of the disease. The patient was killed by the yellow 
toxin which poisoned the entire organism without any 
predominating organic or functional lesion. 

J. L., aged 32, vigorous and laborious, but organi- 
cally enfeebled by excessive work in the sun, lives on 
coarse food, and is in New Orleans since twenty-three 
months. 

The symptoms of congestion are pronounced ; chill, 
vomiting, fades red and glossy, cephalalgia and rachi- 
algia pronounced; pulse, 100; temperature, 104.4 deg. 
The temperature remained without remission at 104.4 
deg. during thirty-six hours, a serious symptom ; a 
still more serious sign is that, notwithstanding ener- 
getic treatment, it rises to 105 deg. Urine free, with 
10 per cent, of albumin on the second day. The fall 
in pulse rate, notwithstanding the elevation of tempera- 
ture on the second da} 7 ," is progressive and without in- 
terruption up to the last moment, as happens in nearly 
all cases of pure Yellow Fever. 

Black vomit on the third, fourth, fifth and sixth 
days, becoming daily more abundant. Albuminous 
urine up to the seventh day. Fever falls with the 
black vomit, reaching in five da}^s 95.5 deg., a defer- 
vescence in six days of nearly ten degrees. 

Icterus on the fourth day. Pulse remains stationary 
at 60 during the period of infection and of black 
vomit, becoming thready and uncountable a few hours 
before death. 



Type: Pure Yellow Fever, 
No. 17— July, 1870. 



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Death. 



Pulse Rate — Faget's Law — Charts. 73 

Observation No. 17. 

This is another observation of typical pure Yellow 
Fever without secondary infection or auto-infection. 
There must certainly be organic lesions since there 
is albuminuria and the renal purification does not occur 
normally, and since there is intense icterus, but they 
do not preponderate as they do in alcoholic subjects or 
in patients organically weak. 

The reader is requested to compare the chart of 
cases of pure Yellow Fever, for, save a few variations 
in the degree of fever, the resemblance is striking. 

The lines of the pulse and of the temperature sep- 
arate, the pulse lowering and the temperature rising 
during the first three or four days ; then, when black 
vomit occurs, the temperature falls and the pulse 
rises a moment before death ; the two curves almost 
form a broken circle. 

C. Iy., aged 28, in New Orleans since three or four 
years, is taken whilst in full health with a chill, gen- 
eral aching, vomiting, high fever, with face glossy, 
cephalalgia, rachialgia. Pulse 120, temperature 104.2 
deg. Slight remission the first night, but the tem- 
perature rises again to 104.8 deg., a grave symptom, 
ranging during two days between 104 and 104.8 deg. 

Defervescence begins with black vomit, reaching 
95.6 deg. The patient urinated almost up to the time 
of his death. Bleeding of the gums on the fourth day. 
Pronounced icterus. 

As in all cases of pure Yellow Fever the fall in 
pulse rate and Faget's law are manifest. 



Type: Fatal Yellow Fever. Pulmonary Hemorrhage. 

jSTo. IS -September, 1807. 



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Death. 



Pulse Rate — Faget's Law — Charts. 75 

Observation No. 18. 

At 8 o'clock in the morning on September 6, 1867, 
J. D., aged 28, a butcher, was taken sick. He is thin, 
of slight build, lives in a damp room. General aching, 
light chills, animated fades, skin hot, covered with 
sweat, gums swollen, slight nausea. Pulse, no; tem- 
perature, 103.8 deg. 

Second Day — Nausea, pain in the back, in the head, 
in the belly, urinated freely, mucous vomiting at night. 
Pulse, 100; temperature, 104.2 deg.; has seven or 
eight stools. 

Third Day — Passed a fair night. General condi- 
tion like yesterday's. 

Fourth Day — Severe pains in abdomen and head, 
nausea. 

Fifth Day — Violent pains in the belly, urine albumi- 
nous and scant3 r . 

Sixth Day — Had a restless night, extreme weak- 
ness, bright yellow color of the eyes, paler over the 
rest of the body, strong epigastric pains, slight bleed- 
ing of the gums, urine scanty, 15 per cent, of albumin. 

Seventh Day — Gums much swollen and bleeding. 
Rusty sputum, prune- juice like. Auscultation nega- 
tive. Entire bod} T is of a yellow mahogany color. 
At 3 a. m. black vomit, black stools, sputum still 
sanguinolent. 

Eighth Day — General condition very grave, bleed- 
ing of the gums, black vomit. 

Ninth Day — Same condition, coldness of extremi- 
ties, bloody sputum, intense icterus, passive erythe- 
matous patches, dark actions, urine free. 

Tenth Day — The hemorrhages continue and patient 
dies in a state of profound anemia, throwing off before 
death a strong cadaveric odor. 

Progressive fall in pulse rate. Faget's law. Yel- 
low Fever complicated with hemorrhage from the 
lungs, the only case I have observed. 



Patient in Feeble Health and Slightly Alcoholic, 
Xo. 19— September. 1S7S. 



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Death. 



Pulse Rate — Faget's Law — Charts. 77 

Observation No. 19. 

Adult, aged 24 years. 

An alcoholic seized with an infectious febrile disease 
is always seriously ill. Attacked by Yellow Fever he 
often dies. During an epidemic the alcoholic and the 
poor devils with the worst lodgement and care give four- 
rifths of the mortality. 

Alcohol damages the same organs as Yellow Fever — 
the kidneys, the stomach, the liver. To the chronic 
lesions produced by alcohol the typhus icteroides adds 
an acute one,' which acts as a spur. At the announce- 
ment of an epidemic all the non-acclimated alcoholics 
should go to the mountains to drink pure water, for 
not only they nearly all die of Yellow Fever, but they 
propagate the disease. In leaving they would save not 
only their own lives, but that of many others. Physi- 
cians should popularize this truth. 

Observation No. 19 testifies to the gravity of Yellow 
Fever in a patient who is even slightly alcoholic. I saw 
the patient on the second day ; on the third day the fever 
rose to 104.6 deg. , with a remission on the fourth day 
to 103.5 deg. Black vomit occurred on the fifth day, 
lasting one day, then defervescence slowly took place 
until the ninth day, when everything led to expect a 
recover}- ; but the lesions of the kidneys became accen- 
tuated, the urine more scant}', Avith 40 per cent, of 
albumin, becoming suppressed on the tenth day. 
Death on the eleventh day of acute nephritis. 

In alcoholics the prognosis must be reserved, unless 
the urine, both in quantity and quality, indicates 
clearly either a fatal issue or a recovery. 

Fall in the pulse rate and Faget's law both manifest. 



Type: Yellow Fever and Alcoholism. 

No. 20— August, 1878. 



Yellow Fever and Nephritis. 
No. n— July, 1878. 



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Death. 



Death. 



Pulse Rath — Fa get's Law — Charts. 79 

Observations No. 20 and No. 21. 

No. 20 is v the clinical chart of a butcher, aged 
29, a confirmed, alcoholic for four years. As in all 
alcoholics taken with Yellow Fever, the urine was 
rare and albuminous as early as the second da}?-. The 
liver, already affected like the kidneys by alcohol, 
became more diseased and intense icterus appeared on 
the third day ; the stomach revolted from the begin- 
ning ; nausea and vomiting during the first twenty- 
four hours. Restlessness, delirium, and profuse sweats 
during the night. Black vomit came on the third da) 7 , 
by which time the scanty urine when heated became 
completely coagulated. On the fifth day, suppression 
of urine and death. The gums, stomach, and intes- 
tines were bleeding since the third da) 7 . 

The patient whose chart is No. 21 was 19, not 
alcoholic, yet on the second day, like the alcoholic, his 
urine became scanty, with 40 per cent, of albumin. 
Intense icterus rapidly showed itself on the third day. 
He had no black vomit. The urine became suppressed 
completely on the fourth day and he died with bladder 
empty on the fifth day, with delirium, a cold, clammy 
and very yellow skin. 

Yellow Fever then can bring all its virulence to bear 
on the kidneys and the liver without anterior lesions 
having been known, as in this patient, in the young 
man of observation No. 15, and the young man of No. 
14. 

Abundant albuminuria on the second day and 
intense icterus on the third day are always very 
grave symptoms. 

The abuse of alcohol produces slowly the same cel- 
lular lesion, fatty degeneration, as a very virulent 
yellow toxin. 

Progressive fall of the pulse. Faget's law is charac- 
teristic. 



Type: Yellow Fever and Alcoholism. 
No. 22— September, 1878. 



Yellow Fever and Nephritis. 
No. 23— October, 1878. 



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Death. 



Pulse Rate — Faget's Law — Charts. 8i 

Observations No. 22 and No. 23. 

J. L., aged 32 years, alcoholic. Fever began in the 
dangerous zone at 104.4 deg. - without remission during 
thirty-six hours, a grave symptom ; exacerbation on 
the second day of .8, rising to 105.2 deg. 

The course of the temperature alone under similar 
circumstances almost surely indicates death. Black 
vomit lasted three days, beginning on the third da}'. 
Albuminuria, 30 per cent., with scant}' urine. On the 
fifth, day the patient ceased urinating and not a drop 
was found in the bladder, notwithstanding several 
catheterizations. 

The progressive fall of the pulse is very remarkable, 
notwithstanding the marked elevation of temperature 
to 105.2 deg. 

In this patient, as in nearly all alcoholics, the con- 
tractions of the stomach lasted three days, causing the 
vomiting of all drinks and of mucosities. On the third 
day the vomit generally becomes black. 

Observation No. 23 goes to show how Yellow Fever 
is always very virulent when it attacks a diseased 
organism, whether it be by alcohol or simply by bad 
food and excessive work. Yellow Fever does not love 
the weak. One must be healthy and strong in order 
to resist the icteroid germ. 

Adult of 22. 

This lack of organic resistance in this instance is 
striking — there has really been no struggle. Fever up 
to 104 deg. on the second day, and already the urine is 
very albuminous ; on the third, fourth and fifth days 
the patient has black vomit ; temperature falls seven 
degrees in four days and death ensues, preceded by 
convulsions and coma. 

Fall of pulse rate and Faget's law both manifest. 



Type: Yellow Fever in the Alcoholic. 
No. 24— Aug. and Sept.. 1878. No. 25— July and Aug, 



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Death. 



Kecovery. 



Pulse Ratk — Faget's I^aw — Charts. 83 

Observations No. 24 and No. 25. 

The patient in No. 24 was a chronic alcoholic, 
drinking for twenty years and having reached an age, 
38 years, at which in virulent epidemics Yellow Fever 
is always serious. 

The fever ranged between 103 and 104 deg. during 
the first three days ; delirium, nausea and vomiting, 
scanty urine, 30 per cent, of albumin on the second 
day. Icterus and black vomit on the night of the 
third day. No more urine on the sixth day and 
death, in horrible convulsions, which caused the tem- 
perature to rise to 104.2 deg. 

It is very rare that death in Yellow Fever should 
occur while fever is yet present. The temperature at 
the time of death is always very low. 

Nearly all alcoholics, having Yellow Kever, die. In 
the very severe epidemics, like in 1867, nearly 100 per 
cent. die. In the less severe epidemics, as in 1878, 
the average is 90 per cent. In 1897, an exceedingly 
benign epidemic, many alcoholics recovered. 

Observation No. 25, of a cured alcoholic is a con- 
soling one. J. B. V., aged 25 years, barkeeper ; was 
drinking a good deal for six years ; notwithstanding 
my apprehension, justified by the knowledge I had 
of his habits, and notwithstanding the high fever, 
104.6 deg. at the outset, the disease ranged like a 
light attack of Yellow Fever. Defervescence took 
place in five days, almost without interruption, the 
fever having lessened almost regularly. The urine 
remained abundant with 5 per cent, of albumin. 
Icterus light. The kidneys and the liver Had not yet 
become affected. 

We must not despair of witnessing the recover}- of a 
drunkard with Yellow Fever, but the proverb ' ' There 
is a God for the drunkard ' ' does not hold good in 
this disease. 



Type: Very Grave Yellow Fever. Hemorrhages. Blaek Vomit. 

Typhoid Aspect. 

No. 26— Oct. and Nov., 1878. 



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Kecovery. 



Pulse Rate — Faget's Law — Charts. 85 

Observation No. 26. 

This observation is very remarkable, typical, and 
instructive. The fall in pulse rate was progressive 
from the outset of the disease to convalescence, with 
two slight increases in rate on the ninth and the 
thirteenth day, same having fallen from 1 18 to 48 
pulsations. The temperature was 103.8 deg. on the 
fourth day ; and, during fifteen days, the fever re- 
mitted in the morning with exacerbations at night, 
presenting the broken descending curve which is ob- 
served in typhoid fever of average intensity, finally 
falling to 96.8 deg. Classical Faget's law. 

This patient was only 20, healthy and temperate, 
having lived two years in New Orleans. He had in a 
rather pronounced manner all the symptoms of the 
congestive period ; the urine remained abundant dur- 
ing the entire disease and albuminous, from 5 to 10 per 
cent. , even during convalescence. A light icterus 
appeared on the fifth day, becoming very intense and 
involving the entire body on the eighth da} r . On the 
ninth day, delirium, bleeding of the gums ; on the 
eleventh day, the patient seemed pretty well, but on 
the twelfth he had black vomit and black stools. 
Black vomit lasted only one day, but frequent bleed- 
ing of the gums and black stools persisted during tour 
days. On the sixteenth day a profound anemia and 
extreme leebleness threatened a fatal termination. 
However, repeated sponging with hot vinegar and the 
administration of coffee, broth, and wine in small 
doses by the stomach and by the intestines assisted the 
organism to rally. The patient slept well on the 
eighteenth and nineteenth days and became conva- 
lescent. I kept him in bed over a month, fearing a 
relapse or a fatal syncope on account of his extreme 
feebleness, 



Type: Very Grave Yellow Fever. Black Vomit. 
No. 27— Sept. and Oct., 1870. 



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Kecovery. 



Pulse Rate — Paget' s Law — Charts. 87 

Observation No. 27. 

Chart No. 27 represents the curves of the disease in 
a person 40 years old who had a very grave attack of 
Yellow Fever, with intense icterus, albuminuria and 
black vomit, and who nevertheless recovered. 

Yellow Fever at that age and above is always very 
grave, and, according to my experience, nearly always 
fatal during severe epidemics. For there are epidem- 
ics and epidemics; the virulence of the microbe is not 
always the same. I shall explain 1113 7 ideas and fur- 
nish proofs on this question in the chapter on prog- 
nosis. 

I saw the patient only on the night of the fourth 
day. He seemed in a desperate state, with black 
vomit; severe epigastric and abdominal pains, gums 
bleeding ; but he could urinate, and the urine con- 
tained only 15 per cent, of albumin. The patient was 
very much depressed, but a symptom which gave some 
hope was that his temperature was yet high, nearly 
104 deg. Black vomit generally brings about a rapid 
defervescence, the fever falling three or four degrees. 
In the cases that recover the fever remains at between 
102 and 104 deg. 

Black vomit lasted only one day, and the urine 
became more abundant ; after seven days of varia- 
tions in the pulse and temperature, without consid- 
erable elevation, the latter became nearly normal, 
the pulse falling to 62 pulsations. The patient 
became convalescent 011 the thirteenth day of the 
disease, very yellow and very anemic. 

When Yellow Fever lasts more than ten days it 
often ends in recovery. 



Type: Yellow Fever and Alcoholism. Atypie Curves. 

No. 28— Sept. and Oct., 1878. 



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Death. 



Pulse Rate — Fa get's Law — Charts. 89 

Observation No. 28. 

This case has absolutely abnormal and atypical 
clinical cur\ es of the pulse and the temperature ; with 
the tracings alone, without clinical history, it would 
not cause us to think of Yellow Fever. 

This young man, aged 18, since two years in New 
Orleans, is a bartender in a well-stocked grocery ; he 
has both a taste for alcoholic liquors and the uncon- 
trollable desires of the dypsomoniac ; he is crazed by 
alcohol. I had already treated him for an attack of 
acute alcoholism with delirium tremens. 

He became ill with Yellow Fever, having: the con- 
gestive symptoms of the outset : chill, cephalagia, 
rachialgia, but, particularly, uncontrollable vomiting 
and profuse sweating. On the second day, the urine 
was 40 per cent, albuminous, icterus appeared on the 
third day, general condition very bad, delirium, rest- 
lessness, nausea, constant vomiting. 

Bleeding of the gums and scanty urine on the fifth 
day, at which time the fever rose like a rocket, 5.4 deg. 
in thirty -six hours. Delirium, excessive restlessness ; 
had to be placed in a strait-jacket. On the night of the 
eighth da> 7 , very abundant black vomit; no more urine, 
and death. 

The symptoms were normal, but the fall of the pulse 
and Faget's law absent. This young man had a tem- 
perature of 106 deg. toward the end of the disease, 
which announced death ; usually it is reached on the 
first or second day. The curves of the pulse and the 
temperature of the last three days are the curves usual 
during the first three days of Yellow 7 Fever ; they are 
inverted, This observation is both rare and curious, 



Type: Grave Yellow Fever. Black Vomit. 
No. 29 — August and September, 1870. 



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Becovery. 



Pulse Rate — Faget's Law — Charts. 91 

Observation No. 29. 

A very grave case of Yellow Fever which terminated 
in recovery, notwithstanding abundant black vomit 
lasting during two days. 

In commenting upon this observation, I desire par- 
ticularly to call the reader's attention to the course 
of temperature during the occurrence of black vomit, 
as it is very important to learn it well for the sake of 
prognosis. 

The case began with a high temperature, 103. 1 deg., 
rising and then remaining during thirty-six hours at 
104 deg. The third day there was a remission of nearly 
two degrees, a very favorable symptom which led me to 
expect a rapid recovery. There was light icterus on 
the fourth day and abundant black vomit on the fifth 
day. Ordinaril} T black vomit causes the temperature 
to fall, the more rapidly as the disease is the more viru- 
lent. In this case the temperature rose a few tenths 
of a degree. The vomiting continued on the sixth 
day, the fever remaining between 10 1 and 10 1.4 deg. 

In such cases I allow the bleeding stomach to 
remain absolutely and completely at rest. No remedy, 
for such is useless, irritating, and increases the vomit- 
ing. I gave enemata of coffee and of broth, and warm 
frictions with vinegar were made every half-hour to 
stimulate the peripheral circulation and prevent col- 
lapse. Black vomit having ceased, the patient 
entered with difficulty into convalescence, in a very 
anemic state. 

I treated this patient in 1870. The epidemic was of 
medium intensity and he was only 19 years old. A 
patient at that age or below with black vomit has 30 
per cent, more chances of recovery than an adult over 
twenty-five years of age. 



Type: Yellow Fever.— Pregnancy.— Suppurative Parotiditis. 

Xo. 30— August, 1S70. 



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Pulse Rate — Faget's Law — Charts. 93 

Observation No. 30. 

The patient, whose chart is No. 30, was a young 
woman 25 years old, in the eighth month of pregnane}', 
a primipara. She was very nervous and very much 
frightened, especially on account of her advanced preg- 
nancy. 

It was the first time that I treated Yellow Fever in 
a pregnant woman, and I did not feel at all reassured. 
In 1878 I treated two other ladies — one two months 
pregnant, who aborted twelve hours after the outset of 
the fever and who recovered ; the second three months 
pregnant, who aborted, had black vomit and profuse 
uterine hemorrhage, and died. 

The symptoms in our patient was very pronounced 
at the outset — -chill, cephalalgia, rachialgia and nausea 
during twenty-four hours. 

The fever was not very high ; the fall of the pulse 
was very accentuated during the first thirty-six hours ; 
then there were slight variations of the pulse and 
the temperature, the general condition remaining good 
until the fifth day, when everything seemed ended, 
without icterus, without albuminuria ; the tempera- 
ture normal and the pulse 76. 

During the night of the fifth, day fever rose again, 
a painful swelling appeared at the angle of the upper 
jaw on the right, with redness and active inflamma- 
tion. On the sixth day the swelling increased and 
strong throbbing pains were felt. Dr. Chopin opened 
the abscess on the eighth da}', finding pus only very 
deeply. 

After evacuation of the pus, convalescence was 
established. A month later the patient gave birth to 
a fine healthy child. Y\ lien pus is formed during 
Yellow Fever recovery follows. In febrile infectious 
diseases parotiditis is always serious. 



Type: Very Grave Yellow Fever. Ecthyma Pustules. Sloughing. 
Late Black Vomit and Epistaxis. 

No. 31— September, 1878. 



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Recovery. 



Pulse; Rath — Fage/t's Law — Charts. 95 

Observation No. 31. 

This observation is interesting. The outset in this 
young man of 15, was not marked by a very high tem- 
perature, 103.8 deg. on the third day. The dangerous 
temperatures are those between 104 and 105 deg., 
lasting two and three days, and the very dangerous 
temperatures those above 105 deg. during the first 
two days. 

The progressive fall of the pulse and Faget's law 
are both well accentuated. Notwithstanding light 
delirium on the fourth day and moderate albuminuria, 
10 per cent., and slight icterus, everything led to hope 
for the beginning of convalescence when, on the sixth 
day, very inflamed ecthymatous pustules appeared on 
the dorsum of both feet, increasing the fever, produc- 
ing sloughing of the skin and a secondary infection 
which led to the recrudescence of the disease. Gen- 
eral condition became bad, sleep disappeared, fever 
rose on the thirteenth day to 104.5, black vomit sur- 
vened on the fourteenth day, abundant, but lasting 
only twelve hours ; on the sixteenth day a pronounced 
epistaxis, then a sensible amelioration and entrance 
into convalescence. 

The long duration of the disease, the abnormal 
features, black vomit on the fourteenth day and a 
critical epistaxis on the sixteenth, a deplorable gen- 
eral condition, the local condition of the feet, with 
sloughing of part of the skin — all led to fear a fatal 
termination. 

His youth saved him. The fever at the outset did 
not indicate great virulence and the patient formed 
pus ; according to my experience one making pus 
during Yellow Fever is likely to get well. 



Type: Very Grave Yellow Fever. Black Vomit. 

No. 32— August, 1870. 



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Pulse Rate — Paget 1 s Law — Charts. 97 

Observation No. 32. 

The young womau furnishing clinical Chart No. 32 
was 21 years old, strong, sound, and enjoying good 
health previous to this disease. 

She fell ill on August 6, 1870, but I saw her only 
on the 9th, the third day of the disease. She had 
black vomit, icterus, rather copious urine, with 5 per 
cent, of albumin. Black vomit lasted three days, 
without being ver} T abundant. In women, black 
vomit does not present the same degree of gravity as 
in men. Women, children, and adolescents often 
have black vomit and get well ; after twenty-five, 
recovery from Yellow Fever with vomito negro is rare. 

In nearly all cases of black vomit the temperature 
ialls rapidly. In this case the temperature remained 
elevated between 101 and 102 deg. during five days, 
then a slow defervescence began. The patient no 
longer vomited, was urinating in large quantities, and 
was sleeping. Sleep in Yellow Fever is an excellent 
symptom, announcing recovery. 

On the fourteenth day the famished patient par- 
took of too much nourishment and had carnis fever 
which yielded to strict diet. Frequently errors of 
diet during convalescence produce indigestion, the 
return of fever and recrudescence of the disease, most 
frequently followed by death. A severe regimen 
must be insisted upon and the patient be allowed to 
rise only when the pulse has become normal and 
strong. 



Type : Yellow Fever and Malaria. 
No. 33 — October and November, 1870. 



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Pulse Rate — Fagkt's Law — Charts. 99 

Observation No. 33. 

Physicians were formerly strong believers in the 
complication of Yellow Fever by malaria. The study 
of Yellow Fever with the thermometer has demon- 
strated to me that it is exceedingly rare that these two 
affections are evolved together or mixed. During a 
long practice I have seen only two cases of malarial 
fever following an attack of Yellow Fever. I observed 
in September, 1897, a case of Yellow Fever with high 
temperature which presented, after four days of ill- 
ness, a very acute attack of malaria fever with com- 
plete intermissions, the fever rising to 105.3 deg. 
The patient recovered after large doses of quinm. 

The second case, which is the more typical, is very 
rare, I believe. I had already treated him for malarial 
fever. He was a gardener, aged 25. All the symp- 
toms of congestion were quite accentuated. On the 
second day the temperature rose to 105.2 deg., an- 
nouncing a grave case. By means of cold sponging, 
of a purgative and of large doses of sulphate of quinin, 
which were well borne, I brought about defervescence, 
and the temperature dropped to normal on the fifth 
day. Fall of the pulse, Faget's law and icterus are 
evident. 

Until the fifth day the tracings of Yellow Fever, 
with very high temperature, are classical ; then, the 
general condition remaining good, paroxysms of 
malarial fever with chill, elevation of temperature, 
and perspiration at the time of remission occurred 
during ten days. The spleen was large and tender. 

Forty to fifty grains of sulphate of quinin daily, 
cold infusions of cinchona, followed by arsenious acid, 
arrested the paroxysms only on the fourteenth day. 
The patient entered convalescence on the fifteenth day, 
cured both of Yellow Fever and of malaria. He had 
five days of Yellow Fever and ten days of fever 
accompanied by the classical clinical curves of acute 
and intermittent malaria. 



Type : Mild Yellow Fever.— Relapse. 

Xo. 34— September, 1870. 



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Death. 



Pulse Rate — Fa get's Law — Charts. ioi 

Observation No. 34. 

Chart No. 34 shows the curves of the pulse and the 
temperature of Yellow Fever in a young woman aged 
24, healthy, though nervous, living in New Orleans 
since five years. 

The disease was ushered in by the characteristic 
symptoms of the period of congestion, violent head- 
ache, aching of the limbs, acute rachialgia, nausea 
during twenty-four hours and moderate fever, 103.4 
deg. Twelve hours later the temperature rose to 
104 deg. The progressive fall of the pulse and 
defervescence of the fever occurred in parallel lines 
as in all very mild cases of Yellow Fever. 

On the fifth day everything seemed well ; pulse, 
50, temperature, 98.4 deg., when the fever returned. 
What was the cause ? I can not certify to it as the 
fact was not acknowledged, but believe it was sexual 
imprudence. 

At any rate, during the second attack the fever rose 
five days consecutively. The pulse was in correla- 
tion with the temperature and rose daily, also, until 
death. The kidneys about ceased functioning on the 
eighth day, the scanty urine containing 60 per cent, 
of albumin ; icterus was very intense ; black vomit, 
without being very abundant, was frequent during the 
last three days. 

This is a striking case of relapse, the curves no 
longer having the physiognomy of those of Yellow 
Fever ; and, as is ordinarily the case, the relapse fol- 
lowed a light attack. Too many precautions can not 
be taken during convalescence. 



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Pulse Rate — Faget's Law — Charts. 103 

Observation No. 35. 

This observation is probably unique in the clinical 
history of Yellow Fever. It is that of the case of a 
young man aged 17 who, twelve hours after the outset 
of Yellow Fever, had a temperature of 106 deg. The 
treatment led to a defervescence in five daj^s. Black 
vomit survened on the sixth day, lasting only a day. 
During ten days there were very marked variations of 
temperature, and it is only on the fifteenth day that 
the patient entered into convalescence ; he was very 
yellow, very feeble, having abundant urination and 
albuminuria no longer. 

The patient remained thirty days without fever, 
eating and sleeping well, regaining his strength. At 
this time he was taken with a second attack of Yellow- 
Fever, or rather a relapsing Yellow Fever. 

The second attack was again very virulent, the fever 
rising to 104.4 deg. Black vomit and black stools 
occurred on the fifth day with a sudden defervescence 
of fever down to 97.2 deg., which seemed to announce 
the end. 

However, the patient was young, without organic 
taint, and had completely recovered from the first 
attack. The temperature rose again by means of 
frictions with hot vinegar, of stimulants such as 
syrup of ether, acetate of ammonia and coffee. The 
black vomit ceased and the patient entered into con- 
valescence on the ninth day, with a normal tempera- 
ture and a pulse beating thirty -eight times a minute, 
lower than I have ever met with. 

There was albuminuria during both attacks, vary- 
ing from 10 per cent, to 15 per cent. ; icterus was 
very pronounced, especially during the first attack. 

The fall in pulse rate and Faget's law were evident 
both times. 

The temperature was quite elevated, even up to 
106 deg., but the acme of the disease was not of long 







Type: Very Grave Yellow Fever. Very Serious Relapse. Black Vomit Both Times. 
No. 35— August, September and October, 1S7S. 


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104 Yellow Fever. 

duration ; in both instances defervescence occurred 
after twelve hours, almost without interruption. 

Black vomit occurred on the sixth day, the first 
time, and the fifth in the second attack ; it lasted only 
twenty-four hours. 

The yellow toxin lessened the rapidity of the 
heart's action to an extraordinary degree the second 
time, the pulse having fallen to 38. What is as con- 
soling as remarkable is that the patient recovered not- 
withstanding the fact that both attacks were intensely 
virulent. 

Relapse ordinarily occurs after a light attack or one 
of moderate intensity and usually after twenty-four 
or thirty-six hours of false convalescence, or after an 
imprudence, the patient rising, walking, or having 
indigestion from excess in eating. 

In this case the relapsing fever occurred thirty 
days after the end of the first attack, the patient not 
having yet left the hospital. He remained two 
months under observation and treatment. 



Conclusions. 

I could multiply these charts of the pulse 
and temperature, and could publish many other 
observations, but they would be similar and 
without important interest. 

Hence, I limit this exposition of clinical 
curves, as I believe that I have presented to 
the reader the most frequent forms and the 
principal types of Yellow Fever as influenced 
by the age of the patient, by the virulence of 
the disease, by organic taints, by auto-infec- 
tion and by secondary lesions. 



Pulse Rate — Faget's Law — Charts. 105 

This work is entirely individual ; it is 
written only in the light of my clinical expe- 
rience and aided by the study and comparison 
of several hundred observations collected 
entirely by me. 

However, as I have seen, observed and stud- 
ied Yellow Fever only in New Orleans, it is 
possible that other varieties may be met with 
elsewhere. 

I hope that the study of my clinical charts 
will bring out the importance of the fall in 
pulse rate and the divergence between the 
pulse and the temperature in the diagnosis of 
typhus icteroides. With the group of symp- 
toms which is so characteristic of the period 
of congestion, the physician should always 
recognize Yellow Fever. 

Facts which are ever to be remembered are 
as follows: 

In mild cases the pulse and the temperature 
fall without interruption in parallel lines. In 
cases of moderate intensity, the fall in pulse 
rate is uninterrupted and progressive, accom- 
panied by elevation and variation of temper- 
ature, lasting twenty-four and seventy-two 
hours. In grave cases the fall in the pulse 
rate is progressive during three days, the fever 



106 Yellow Fever. 

ranging during three and four days between 
103.5 all d io 4-5 deg., with exacerbations at 
night and remissions in the morning. In very 
grave cases, the pnlse diminishes in frequency 
progressively, or remains stationary during sev- 
eral hours, while the temperature rises rapidly 
in twelve or eighteen hours, to the dangerous 
and frequently fatal zone of 105 deg. and above. 
In the very virulent and most often fatal cases of 
Yellow Fever, without predominating organic 
affections, the fall in the pulse is progressive 
and very accentuated, the temperature reach- 
ing from the outset of the disease 105 deg., or 
above. In cases of Yellow Fever, accompanied 
by organic taints produced by alcohol, exces- 
sive work, or, briefly, excesses of all kinds, the 
fall in the pulse rate is manifest, the tem- 
perature rising beyond 105 deg., or ranging 
between 104 and 105 deg., with rapid defer- 
vescence in almost a perpendicular line, when 
black vomit begins and the patient is to die, 
and remaining at an elevation between 10 1 and 
104 deg., when the patient has chances of 
recovery. 

Hence, it is the clinical chart of the pulse 
and the fever which furnishes the most useful 
indications for diagnosis, prognosis and treat- 



Pulse Rate — Faget's Law — Charts. 107 

merit. In a disease as virulent and with as 
rapid a course as Yellow Fever, it is of inesti- 
mable value to have as guides in the care 
of the patient two indicators as precious and 
positive as the watch and the thermometer, 
which never deceive the physician. 

I know of no febrile infectious disease in 
which the physician can within the first twenty- 
four hours, after several examinations of the 
patient and his symptoms, and of the pulse and 
the temperature, be so usefully and completely 
enlightened as he can be in Yellow Fever. 



CHAPTER IV. 



YELLOW FEVER IN CHILDREN — CLINI- 
CAL CHARTS OF PULSE AND TEM- 
PERATURE—OBSERVATIONS. 



Thirty-five years ago the dogma was that 
children born in New Orleans never contracted 
Yellow Fever. 

It was the fixed opinion of all the most dis- 
tinguished physicians of that city. Dr. Delery 
was the only refractory one; he proclaimed 
against these erroneous ideas, and with much 
good judgment and clinical sense declared that 
Creole children did have Yellow Fever, but 
ordinarily in a very light form. 

During the epidemic of 1866 and 1867, by 
studying this disease in children with the aid of 
the thermometer, I found the same symptoms, 
their same succession, and the same curves 
of pulse and temperature as in the adult. 
My observations came to strengthen and dem- 
onstrate the ideas of Dr. Delery. Wish- 
ing to cause them to prevail, I had, thirty 



108 



YEivLOw Fever in Children — Charts. 109 

years ago, an animated debate with my friend, 
Dr. Faget, who was the most eloquent and 
bitter defender of the theor}^ of the absolute 
immunity of Creole children. 

Legends die hard ; this one succumbed only 
after the epidemic of 1878, when the disease 
attacked a large number of children and was 
observed by means of the thermometer by all 
physicians. 

Yellow Fever is exceedingly mild in children 
if disturbing treatment is not resorted to. 

According to my experience it is certainly 
lighter than measles, and, as far as I am con- 
cerned, I would prefer to treat one hundred 
cases of Yellow Fever in children than seventy- 
five of measles. I would certainly have a 
smaller mortality in Yellow Fever. 

This benign type of the disease is what had 
led to the belief in the immunity of children 
born in New Orleans. Every year up to 1878 
there were a few or many cases of Yellow 
Fever. Children became acclimated by taking 
the disease during infancy; the attack of 
fever lasted one, two, or three days without 
alarming symptoms and caused no uneasiness 
to the family. Children nearly always recov- 
ered, and the cause of the indisposition was 
unrecognized. It was really Yellow Fever, 



no Yellow Ff:ver. 

However — acclimating fever, attenuated Yellow 
Fever. 

The grave or fatal cases were credited to 
malaria and a new morbid entity had even been 
invented for the occasion, Hemorrhagic Mala- 
rial Fever, which existed and was observed 
only at times of epidemics of Yellow Fever 
and which was nothing else than Yellow Fever 
in the Creole, accompanied by black vomit. 

By means, of the thermometer I did justice to 
these erroneous ideas, which, as I said to Dr. 
Faget, were an outrage on General Pathology. 

Yellow Fever in children presents the same 
form and the same type as in adults ; the fall 
in pulse rate and Faget' s law are as charac- 
teristic ; the invasion is the same and the 
symptoms of congestion are alike. Nausea 
and vomiting are more frequent, as well as 
epistaxis ; the pulse does not always show a fall, 
as it is influenced by the nervousness, the tears 
and cries and the movements of the child. 

I shall publish a few clinical charts of Yel- 
low Fever occurring in young children, includ- 
ing light, grave, and fatal cases ; in comparing 
these charts and observations with those of 
adults, it will be plainly showm that the disease 
is always the same. Age does not change the 



Yellow Fever in Children - — Charts, hi 

physiognomy of the disease, but only attenuates 
its virulence. 

During an epidemic of Yellow Fever anxiety 
for the children almost crazes the parents ; for 
their sake one is frightened, and without reason, 
as the mortality among them is almost nil. 

In 1878, I had under my care 105 children ; 
of these, eleven had slight black vomit and I 
only lost two, observations of whom I shall 
publish. 

The epidemic of 1S97 was very much milder 
than that of 1878. It prevailed especially 
amon^ children. The mortality was exceed- 
inglv light ; assuredly not one case in 200 sick 
children. 

Several physicians whom I could name 
treated more than 100 children each with Yel- 
low Fever last year without a single death. 
Hundreds of families, terrified by odious 
measures of house quarantine, treated their 
own children without calling in any physician 
and with the greatest success. 

I mention these facts in order that, during 
times of epidemics of Yellow Fever, parents, 
and especially mothers, may not become 
alarmed and lose their head, for I can not re- 
peat too often : in children. Yellow Fever 
properly treated is less dangerous than measles. 



Type : Mild Yellow Fevep, 
~So. 1 — September, 1878. Xo. 2— September, 1878. 



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Recovery. 



Recovery. 



Yellow Fever in Children — Charts. 113 

Observations No. i and No. 2. 

The child whose observation is No. 1 was a robust 
boy aged 8^. While in full health he was taken 
with a chill and fever, and violent headache ; severe 
pains in the back ; aching in all the limbs ; nausea and 
vomiting, first of aliments, then of mucous substance. 

Three of his sisters had the fever during the same 
epidemic and one of them died. 

During the course of the disease, the two curves of 
the pulse and temperature ranged in parallel lines, 
the fever rising at the second visit .4 deg. , the pulse 
decreasing by fifteen pulsations. Faget's law. No 
albumin or icterus. 

The child whose chart is No. 2 was a strong, 
healthy, big boy who had never been sick before. 
He was suddenly taken with fever, at 104 deg. ; violent 
cephalalgia and rachialgia; restlessness, and vomiting. 
Children react in a more pronounced manner and 
show all the symptoms of invasion to a greater extent 
than adults. During three days the fall in pulse rate 
and defervescence of fever occurred in parallel lines. 
On the third day there was some collapse, extreme 
pallor, coldness, severe sweating. 

Hot frictions and light stimulation, cognac, hot 
wine, and coffee, quickly overcame it. This occur- 
rence frightens greatly but is without seriousness. 

There was great feebleness during eight days, not- 
withstanding a voracious appetite ; such we must be 
careful not to satisfy. 



Type : Yellow Fever of Moderate Intensity. Mild. 

Xo. 3— Aug. and Sept.. 1878. Xo. 4— Sept. and Oct., 3878. 



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Recovery. 



Kecoverv. 



Yellow Fever in Children — Charts. 115 

Observations No. 3 and No. 4. 

The little girl whose chart is No. 3 was 4 years old, 
and had not been sick since birth. Yellow Fever was 
ushered abruptly, with high temperature, active con- 
gestion of the face. The child complained particu- 
larly of her head, was restless, crying and screaming. 
The temperature of 103.5 deg. a t the outset rose in 
twenty-four hours to 104.6 deg. She was very nervous 
and had delirium. Tepid baths repeated ever}" hour 
nicely produced a defervescence, the temperature fall- 
ing to 99.4 deg. in three days. The fall in pulse rate 
is typical, progressive and uninterrupted during three 
days, then there are variations in the pulse until 
convalescence. 

Faget's law is as well shown as in the adult. In 
forty-eight hours the temperature rises 1.1 deg., from 
103.5 to 104.6 deg., and during that time the pulse 
diminishes from 140 to 100 pulsations, or a fall of 40. 
The law is as much pathognomonic in the child as in 
the adult. Convalescence was slow, extreme weakness 
lasting one month, appetite voracious; jaundice began 
on the fourth day, becoming more accentuated on the 
following days. 

Chart No. 4 is that of a light case in a child 11 
years old, taken suddenly in the night with fever ; 
general aching, vomiting of aliments, and a congested 
face. There was epistaxis on the third day. Ordi- 
narily in children epistaxis occurs during the first 
twentv-four hours. 



Type : Yellow Fever of Medium Intensity. Mild. 

No. 5— October. 1878. No. 6— August, 1878. 



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Recovery. 



Recovery. 



Yeleow Fever in Children — Charts. 117 

Observations No. 5 and No. 6. 

In publishing these charts of Yellow Fever in chil- 
dren I desire specially to demonstrate that in the lat- 
ter, as in adults, the pulse rate falls most frequently, 
or remains stationary, as in Chart No. 5, when the 
fever rises without the law of the fall in pulse rate 
being on that account violated. 

The fever in Case No. 5, a child of 6, was very 
high, 104.4 deg. , diminishing two degrees in twelve 
hours. The next day there is an exacerbation of 2 3 
to 104.9 deg. 

During this rise the pulse remained stationary at 
126, beginning to fall progressively from the third day 
and continuing without interruption up to the time of 
recovery. Faget's law is characteristic. The only 
alarming symptom was the high temperature, which 
yielded to treatment consisting of tepid baths and cold 
sponging. 

In Chart No. 6, child 9 years old, is shown a pro- 
gressive and uninterrupted fall in pulse rate, the tem- 
perature falling also, except on the second day, when 
there was a slight exacerbation, .4 deg., the pulse 
diminishing by ten pulsations. Faget's law. 

In 1867 I treated at this patient's house a young 
Frenchman, a nephew, aged 21. He had a severe 
attack of Yellow Fever, followed by recovery. There 
were then three children in the house, who all had a 
light attack of Yellow Fever. From 1867 to 1878 the 
family was increased by four other children. All four 
had Yellow Fever in 1878, and I nearly lost the child 
whose chart is No. 6. The oldest three, who had been 
sick in 1867, remained free. The seven children then 
had Yellow Fever — three in 1S67, four in 1878 ; all 
recovered. In the same block there were in 1878 more 
than 100 cases with twenty-five deaths. 



Type : Grave Yellow Fever. 

No. 7— October, 1878. 



Yellow Fever of Great Gravity, 

No. 8 - October, 1878. 



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Recovery. 



Recovery. 



Yeleow Fever in Children — Charts. 119 

Observation No. 7 and No. 8. 

While in full health, P. P., aged 4 years, was taken 
with a high lever, 104 deg. ; his face w r as red and 
glossy and he had nausea and vomiting during twenty- 
lour hours. General aching ; restlessness ; dry tongue. 
Pulse 135, By means of cold sponging every hour and 
two baths, the fever fell one degree during the first 
twenty-four hours. The next day it rose 2.1 to 105.2 
deg. Prostrated by this high temperature, the child 
lell into an alarming comatose condition which lasted 
several hours. I had him sponged every quarter of 
an hour until the temperature fell to 104 deg. ; then 
every half hour and, by this treatment alone, a satis- 
factory defervescence was produced, the fever dimin- 
ishing one degree daily during five days, or slowly, 
as occurs with a permanent fall. During the first two 
hours the sponging produced coldness of the surface 
with cyanosis, which alarmed the parents, but as the 
temperature was yet over 104.5 deg., I continued 
them, administering brand}' at the same time. Con- 
valescence was rapid. . 

Observation No. 8 is that of a child nine years old, 
who had Yellow Fever of a remittent type, with 5 
per cent, of albumin on the third day. He had 
slight black vomit on the fifth day and icterus on the 
sixth. The temperature diminished intermittently 
during five days. 

The pulse remained stationary during two days 
while the fever was rising. The temperature fell 
gradually during eight days to 95.8 deg. The situa- 
tion was alarming on the third and on the fifth day, 
but the child recovered. 



Type : Grave, Remittent Yellow Fever. 

jSTo. 9— September, 1867. 



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Recoveiy. 



Yellow Fever in Children — Charts. 121 

Observation No. 9. 

Rose S., a little child 8 years of age, was taken sick 
on the morning of September 6, 1878, with high fever 
and vomiting. I saw her at night ; the fever was then 
very high, 105.2 deg., the pulse 140, and she was com- 
plaining of violent pains in the head, in the back and 
in the limbs. Her face was scarlet, and she was in a 
state of drowsiness out of which she roused only to 
vomit. 

I ordered cold sponging every half hour, and pre- 
scribed digitalis and veratrum viride. 

The fever during the first three days decreased, as 
well as the pulse, in parallel lines. 

On the third day treatment was discontinued and 
light nourishment was given ; but, as the fever rose 
again during the night, the cold spongings were 
resumed. 

On the fourth day there was slight black vomit, and 
albumin showed in the urine. All food and drink 
were stopped, and there was no more black vomit by 
the fifth day. 

On the sixth day jaundice was well marked, and by 
the eighth day the child was in full convalescence. 

This observation is interesting, as it shows the 
danger of fever above 105 deg. , in the case of a 
child, as well as that of an adult. The treatment 
by means of digitalis and veratrum acted on the 
symptom — fever, but the disease followed its regular 
course. 

The pulse fell with but slight variations, notwith- 
standing exacerbations of fever of two degrees. 



Type: Yellow Fever of Great Gravity. 



Xo. 10— August. 1ST 



Xo. 11 — Aug. and Sept.. 1S78, 



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Death. 



Death. 



Yellow Fever in Children — Charts. 123 

Observations No. 10 and No. ii. 

F. E. was a bright child, aged 8 years, of nervous 
temperament and enjoying good health. 

She fell sick at 4 A. m., on August 27, 1878. High 
fever, 103.6 deg. ; face glossy; repeated vomiting; 
violent pains of the head and back. By night she had 
become semi-comatose, her face being excessively pale 
and the fever had risen to nearly 105 deg. 

On the second day the fever had again risen, being 
105.2 deg. , which was a symptom of grave import ; the 
urine had become scanty and contained 20 per cent. 
of albumin. The comatose condition was persistent, 
and the child made only inco-ordinate movements. 
Her general condition was very serious. By the 
third day, no secretion of urine ; black vomit abun- 
dant and frequent ; she had black stools. Character- 
istic fall in pulse rate and Faget's law. Death on 
the fifth day. Cadaver was yellow, showing large 
ecchymoses. 

No. 11. — This little boy, aged 4 years, was the 
brother of F. K-; he was taken sick two days later 
than his sister. 

High fever ; nausea ; suffusion of the face ; lumbar 
pains ; tongue white. Fever fell 1.6 deg. during first 
thirty-six hours, but, during the night of the second 
day, it rose three degrees, reaching the very dangerous 
zone of 105 deg. The child was restless and delirious. 
Defervescence occurred on the third da} 7 . He vomited 
black several times, and the urine was scanty. Throw- 
ing his head from side to side, he had not a moment's 
rest. All might not have been lost, but, notwithstand- 
ing my prohibition, four fly blisters were applied by 
the mother, and the urine became entirely sup- 
pressed. Death on the fifth day. 



124 Yeeeow Fever. 

Conclusions. 

It is easy to find, in this collection of eleven 
clinical charts of the pnlse and temperature in 
children, the same type of Yellow Fever as in 
the adult. 

In children, the symptoms of the period of 
congestion are more accentuated; vomiting, 
pains, congestion of the face, delirium ; but the 
secondary lesions of the kidneys and the liver 
are much more rare. Black vomit especially 
has not the same gravity. 

Very virulent Yellow Fever, or that attack- 
ing an enfeebled constitution, is evidenced in 
the child as well as in the adult, by the rapid 
succession of such symptoms as show the 
gravity of the disease; temperature reaching 
105 deg. or above; albuminuria on the second 
day; black vomit and icterus on the fourth 
day ; suppression of urine. 

The disease is absolutely the same in the 
child as in the adult, and the two laws of the 
fall in pulse rate and of the divergence between 
the pulse and the temperature are just as 
characteristic. 



CHAPTER V. 



DIAGNOSIS OF YELLOW FEVER. 



To diagnose Yellow Fever means to recog- 
nize it every time it exists. To recognize it 
and to differentiate it after two or three visits 
from other acnte pyrexias, which have some 
traits in common during the period of invasion 
only, it is necessary to know thoroughly its 
symptoms and their succession, to know the 
day upon which a given symptom ordinarily 
appears, and especially to have an exact con- 
ception of the fall in pulse rate and of 'Faget's 
law, which are pathognomonic phenomena met 
with only in typhus icteroides. 

By means of the proper grouping of the 
symptoms of invasion and of the curves of the 
pulse and the temperature, the diagnosis is 
more than easy, it actually obtrudes itself 
within the first thirty-six hours. It is unneces- 
sary to wait for albuminuria, icterus, black 
vomit, suppression of urine. 

125 



126 Yeeeow Fever. 

Diagnosis of the disease is not sufficient, it 
is also necessary to diagnose the patient, in 
order to appreciate the degree of resistance of 
his organism. It is nnnecessary for me to 
insist npon this point further than to state 
that, clinically, one is as important as the 
other. In order to be able to treat the patient 
it is necessary first to know what he has. 

The first two or three observations of the 
patient most frequently enable the physician to 
diagnose the disease, especially if the patient 
is seen at the outset of Yellow Fever, but the 
diagnosis of the patient must be studied daily, 
at each visit, and as long as lasts the morbid 
evolution; for, it is by comparison, by suc- 
cessive conclusions as to the general condition 
of the patient, and by suggestions furnished 
through the symptoms that the physician 
should be inspired in formulating the prog- 
nosis and in guiding the treatment. 

Since the time that the genius of Pasteur 
has enlightened us as to the genesis of 
febrile infectious diseases and demonstrated 
that each is produced by a specific germ, etio- 
logic diagnosis has assumed a very great im- 
portance. 

When the Klebs-LcefHer bacillus is found in 



Diagnosis of Yeeeow Fever. 127 

a culture of false membrane taken from the 
tonsil, the diagnosis of diphtheria is made: 
when Koch's bacillus is found in the sputum, 
the diagnosis of tuberculosis is established ; 
such is the case in many other bacillary 
diseases. 

Dr. Sanarelli, while studying Yellow Fever 
at Montevideo, isolated and cultivated a 
microbe which, when inoculated in animals, 
has produced the symptoms of typhus icte- 
roides and the same anatomical lesions as in 
man. 

Dr. P. E. Archinard, of New Orleans, as well 
as other bacteriologists, have found Sanarelli' s 
bacillus during the epidemic of 1897 ni the 
organs of many patients having died of Yellow 
Fever. 

The studies and experiments of Sanarelli, 
repeated in the laboratories of New Orleans, 
have fully confirmed the result obtained at 
Montevideo. 

Upon reading Sanarelli's reports upon his 
discovery, one is convinced that his bacillus 
icteroides is the pathogenic bacillus of Yellow 
Fever. Still, I would like to see his valuable 
discovery confirmed and endorsed by the great 
bacteriologic institutes of Paris and of Berlin. 



128 Yellow Fever. 

The sanction of the anthorities would give it 
absolute certainty and is indispensable from 
the fact that the medical public has already been 
informed on eleven occasions that the true 
microbe has been found, only to be disap- 
pointed eleven times. I do not believe that 
this will be the case with Sanarelli's announce- 
ment. 

By means of more than ioo well conducted 
experiments, Dr. P. E. Archinard has demon- 
strated that the serum of blood taken from a 
Yellow Fever patient agglutinates Sanarelli's 
bacillus and that this phenomenon of agglu- 
tination, generally accepted for the diagnosis 
of Typhoid Fever through the labors of F. 
Widal, is produced in Yellow Fever seventy- 
five times in a hundred. 

This is again a precious method of diagnosis 
which can, at the beginning of an epidemic, aid 
in recognizing in a rapid and scientific manner 
the existence of Yellow Fever. Archinard ob- 
tained agglutination with blood drawn on the 
second day of the disease. It would be highly 
useful to know if the phenomenon can be pro- 
duced by means of serum on the first day. 
This is probable, for I was assured by the dis- 
tinguished bacteriologist that the serum ob- 



Diagnosis of Yellow Fever. 129 

tained on the second day produced aggluti- 
nation more rapidly then the serum of the 
third or fourth day. 

The agglutination test would, at the begin- 
ning of the epidemic, with the indispensable 
aid of the clinical observations, enable us to 
make an early and positive diagnosis; urgent 
measures might then be taken to try and pre- 
vent the establishment of a focus. It would 
be necessary to isolate the first cases outside 
of the threatened city and thoroughly to dis- 
infect the apparel, the room, and the house of 
each patient. 

The application of these laboratory discov- 
eries will be very useful during epidemics of 
Yellow Fever and, in doubtful cases, the cult- 
ure tube and the phenomenon of agglutination 
will act as a check on or corroboration of the 
bedside observation ; but the scientific diag- 
nosis can never take the place or even dimin- 
ish the importance of the clinical diagnosis. 

Intensity of the fever, its exacerbations, its 
remissions, functional troubles, a very acute or 
benign course of the disease, will always fur- 
nish the most indispensable data for the proper 
treatment of the patient. The laboratory can 
only furnish the label of the disease whilst a 



130 Yellow Fever. 

carefully taken clinical observation will give 
the therapeutic indications which can aid in 
curing the diseased organism. 

It seems almost impossible to commit an 
error in diagnosis when Yellow Fever is viewed 
during its complete evolution from invasion to 
termination; when all the principal S3onptoms, 
which succeed each other nearl} r always in the 
same order, are aligned ; and, especially, when 
it is remembered that the yellow typhus is 
characterized ninety times in a hundred by 
the fall in pulse rate during the first seventy- 
two hours and by a divergence between the 
pulse and the temperature. When an epidemic 
exists in a city ; when the cases showing char- 
acteristic symptoms are multiplying in a house, 
on a street, in a neighborhood ; when it is es- 
pecially non-acclimated people who fall ill, 
while those who have already had Yellow 
Fever remain well, doubt no longer exists and 
no physician can hesitate to say to the family ; 
" This is a case of Yellow Fever." 

Hesitation is possible for the first cases only, 
when they are mild or of moderate intensity, 
and when no exacerbation of temperature 
occurs, which is a possibility, but of rare 
occurrence. It is also very difficult to make a 



Diagnosis of Yellow Fever. 



131 



positive diagnosis when the patient is seen 
only on the third or fourth day of the disease 
and when the observation has either been poorly 
taken or not at all recorded. 

In light cases the phenomena of congestion 
may be accentuated ; cephalalgia, rachialgia, 
vomiting and the facial aspect may exist, 
but as the pulse and temperature fall in par- 
allel lines, the pathognomonic sign of lack of 
correlation between the pulse and temperature 
is missing. There is no albuminuria and no 
icterus. The fever is one of a single paroxysm 
and lasts two, three, four and even five days. 

In such light cases the clinical diagnosis 
must be reserved, but the information obtained 
as to the surroundings of the patient may 
assist in clearing the situation. 

Should one learn that the patient comes 
from an infected point, or one that may be so ; 
that the patient has never had Yellow Fever ; 
that members of the family or neighbors have 
been taken suddenly ill, presenting about the 
same symptoms ; that he has arrived by ship 
from a port infected with Yellow Fever, and 
that there have been other patients on board, 
or deaths at sea, these various informations 



132 Yellow Fevp;r. 

may be grouped and a positive diagnosis may 
be reached. 

As far as the patient and the physicians are 
concerned, a positive diagnosis has no great 
importance in light cases, as recovery is the 
rule and the treatment is merely hygienic — 
rest, fresh air, Vichy water in abundance. 

Doubtful cases must be treated just as if 
they presented no doubt as to diagnosis. 

For cities like New Orleans, however, where 
Yellow Fever comes always from importation, 
an early diagnosis, even in the light cases, is 
very important on account of the sanitary 
measures which must be taken, in order to 
prevent the propagation of the disease if pos- 
sible. 

When severe cases of Yellow Fever are 
observed at the outset of an epidemic, a doubt- 
ful diagnosis is no longer permissible. A fall 
in the pulse and a divergence between the 
pulse and temperature, coining after the symp- 
toms of congestion such as cephalalgia, rach- 
ialgia, and vomiting, give absolute certainty 
within the first three days, made doubly sure 
by albuminuria, icterus and black vomit. 

Since the introduction of the thermometer 
in the study of fevers, observation of the pulse 



Diagnosis of Yeeeow Fever. 133 

has fallen into desuetude. The older physi- 
cians had greater consideration for the mani- 
festations of the pulse, and I believe they 
were right. To-day we feel the pulse to see if 
it is strong or weak, frequent or irregular, but 
many physicians never count it. It is wrong, 
and, within the Yellow Fever zone, it is an 
error. 

It is needless to remind the reader that, in 
New Orleans and in the cities of the United 
States situated on the coast of the Gulf of 
Mexico, Yellow Fever occurs only from Ma) T 
to November, from the beginning of the hot 
season to the first cold spell, and that the 
month in which are observed the symp- 
toms which might suggest Yellow Fever must 
be taken into account when making a diagno- 
sis. 

It is evident that in December, January, 
February, March or April, the idea that a 
patient may have Yellow Fever can nearly 
always be discarded. I say nearly alwa\ T s, for 
as Renan has said: " Eve^thing happens, even 
winning the capital prize in the lottery." 
Many infectious diseases have an outset simi- 
lar to that of Yellow Fever — chill, burning 
fever, congestion, and general aching; but, in 



134 Yellow Fever. 

all of them, the pulse remains in correlation 
with the temperature and, while the fever 
remains stationary or rises, a fall in the pulse 
is never observed. 

In malarial fevers, with catarrh of the 
stomach, bilious vomiting, intense chill and 
high temperature, the pulse is always very 
rapid, and does not decrease as long as the 
fever remains elevated. If intermittency occurs, 
the disease can be decided upon within twelve 
to eighteen hours. In typhus icteroides the 
fever never lasts only twelve or twenty-four 
hours; the lightest cases last at least three days. 

In malarial remittent fevers, which last 
sometimes three and four days and more, there 
is never a fall in the pulse rate nor a diver- 
gence between the pulse and the temperature; 
also, the congestive pains are not localized in 
the head and the back, as in Yellow Fever; 
the pains are more general, and more in the 
nature of muscular and articular malaise; the 
face does not take on a glossy appearance; 
albumin is rarely found in the urine, whilst in 
Yellow Fever a temperature between 104 and 
105 deg., and especially above, should it last 
at least twelve hours, always produces albu- 
minuria. 



Diagnosis of Yellow Fevek. 135 

The spleen is often enlarged and tender 
npon pressure in Malaria; there is no such 
condition in Yellow Fever. 

Finally, if a difference in symptoms yet 
allowed a doubt, the microscopical examina- 
tion of the blood would show Laveran's hema- 
tozoa, the plasmodium, which would settle the 
difficulty. 

Yellow Fever has been mistaken for remit- 
tent bilious fever, the hemorrhagic fever of 
warm climates, but, as has been well said by 
Dr. Rochefort in his excellent article on Yel- 
low Fever, in the Diction na ire Eficyclopedique 
des Sciences Medicales, " The prolonged chill, 
the early appearance of dark urine, of intense 
icterus, and of persistent pains in the hypo- 
chondrium; its intermittent or remittent feb- 
rile type; its rare and slight hemorrhages, are 
in marked contrast with the scanty and clear 
urine, the more tardy icterus and the serious 
hemorrhages, especially from the stomach, in 
Yellow Fever." 

This form of bilious fever is very rare in 
New Orleans ; I have observed three cases 
in thirty-three years : the first was in an alco- 
holic who, with a temperature above 105 deg. 
and an intense icterus, had blood in the urine 



136 Yellow Fever. 

eighteen hours after the outset ; the two others 
were in sailors on a ship from Colon, where 
the disease constantly exists. In neither of 
the three cases was there a fall in pulse rate, 
nor Faget's law. The first patient died on the 
third day, having a liver enormously enlarged; 
the two sailors were cured with large doses of 
sulphate of quinin. AYhile treating these 
three patients, the idea did not suggest itself 
that they might have Yellow Fever, so differ- 
ent were the symptoms and especially the 
evolution, from those of Yellow Typhus. 

During the last epidemic which prevailed in 
Xew Orleans and in several adjoining States, 
the question of the diagnosis between Dengue 
and Yellow Fever was much discussed by 
physicians. The epidemic was so mild, almost 
without mortality, and attacked chiefly children, 
so that it was long before it was officially de- 
clared to be Yellow Fever. 

I haA'e already spoken of the scientific and 
the clinical diagnosis ; the commercial diag- 
nosis must be added to the list ; it is that which 
denies the existence of Y^ellow Fever, or calls 
it by another name in order to avoid quaran- 
tine and a cessation of traffic. This diagnosis 
at times of light epidemics, such as that of 



Diagnosis of Yellow Fever. 



o/ 



1897, is only one of bad faith ; but, in a serious 
epidemic, it could cause many victims. 

In 1876, I had occasion to study Dengue in 
New Orleans by means of the thermometer and 
the watch, and, among the numerous cases 
treated by me, never did I notice in any symp- 
toms, save those of invasion alone, nor espe- 
cially in the succession of those symptoms, 
anything which might lead a well-posted physi- 
cian, knowing both diseases thoroughly, to take 
one for the other. 

It can not be repeated too often that it is not 
by means of one symptom but by the collection 
of symptoms and their succession that a diag- 
nosis should be made. 

Guided by the most recent works on Dengue, 
I shall give a symptomatic description of that 
disease, showing the fundamental differences 
existing between it and Yellow Fever. 

Dengue is an epidemic, contagious, febrile 
disease essentially characterized by articular 
and muscular pains and accompanied by poly- 
morphous eruptions. 

Yellow Fever is also epidemic, contagious, 
and febrile, but the pains characterizing it are 
especially rachialgia and cephalalgia. It is 
never accompanied by polymorphous eruption. 



138 Yellow Fever. 

The popular names given to the diseases 
help to differentiate them, Dengue being 
variously designated as dandy fever, articular 
rheumatism of warm climates, break-bone 
fever. 

The invasion of Dengue is similar to that 
of Yellow Fever and is also ushered by a chill. 
The fever is generally of one paroxysm, reach- 
ing its maximum within two hours after the out- 
set. " The pulse always follows the oscillations 
of the fever," says Dr. de Brun, who has ob- 
served and thoroughly studied this disease in 
the Orient. " It varies between 100 and 130, and 
in some cases there is a slowing of the pulse, 
especially during convalescence." 

It is only in very mild cases of Yellow Fever 
that there is only one paroxysm, whose maxi- 
mum is at the outset. The maximum is more 
frequently on the second day and the exacer- 
bations and oscillations last five and six 
days. The pulse is never in correlation with 
the temperature ; on the first three days it is 
falling. The slowing of the pulse in Yellow 
Fever occurs on the fourth or fifth day, and 
especially during convalescence, as occurs in 
Dengue. 

This phenomenon of the slowing of the pulse 



Diagnosis of Yellow Fever. 139 

in Dengue has impressed certain physicians, 
although it is produced only at the termination 
of the disease, while the phenomenon of pro- 
gressive fall occurs only during the first three 
days of Yellow T Fever. 

Many physicians, as I have too often 
observed, have not an exact idea of the phe- 
nomenon of the fall in pulse rate. They 
believe that fall in rate is synonymous with 
slowness. This is a positive error. 

The fall in pulse rate is a progressive low 7 - 
ering of the pulse. A pulse can fall and still 
be quite frequent and far from being slow. 
A low or a slow pulse is a pulse below the 
normal rate, or below seventy pulsations. A 
pulse is falling only when at each observation 
the pulsations are found to have diminished in 
number. 

A pulse of 120 is very frequent; it falls in 
rate to no, it is yet very frequent; it again 
falls to 100, it is still frequent; to 90, it has 
again fallen, though it is yet frequent. Dur- 
ing the interval of these four observations it 
has fallen by 30 pulsations; there is a marked 
fall in its rate progressively, uninterruptedly, 
but it is not a slow pulse, for a pulse of 90 is 



140 Yeelow Fever. 

yet a pulse 20 to 30 beats above the normal 
rate, which is about 70 or 60. 

This phenomenon of fall in the pulse rate 
is met with only in Yellow Fever. 

A slow pulse is met w T ith in many affections ; 
frequently in basic tubercular menengitis; 
during convalescence in dengue; in the pneu- 
monia of children, according to Dr. Comby; 
also in the convalescence of Yellow Fever, as 
one can see in my charts. I note once a pulse 
as low even as 38. 

The fall in pulse rate is a phenomenon of 
the first days of Yellow Fever ; the slowing of 
the pulse is a phenomenon of the last days of 
dengue, particularly of convalescence. 

Returning to the symptoms, we find that the 
acute pains of dengue select particularly the 
large and small articulations and muscles. 

In Yellow Fever the classical pains are 
cephalalgia, which exists also, it is true, in 
Dengue; and rachialgia, which is less pro- 
nounced in Dengue. In Yellow Fever the pain 
is never localized in the articulations nor in 
the muscles, while in Dengue there is very 
violent myalgia (de Brun). 

The exanthem of Dengue is produced twice. 



Diagnosis of Yellow Fever. 141 

First, the initial rash, which does not always 
occur, or may pass imperceived ; when occur- 
ring, it consists of an intense congestion of the 
face and the body surface, which might be mis- 
taken for the congestion of the face in Yellow 
Fever if in Dengue this eruption was not 
almost invariably accompanied by a more or 
less extensive edema, which may exist without 
redness. This edema never occurs in Yellow 
Fever. The second or terminal rash is char- 
acterized by being polymorphous, simulating 
the exanthem of measles, then that of scarla- 
tina or of urticaria. The eruption covers the 
hands, the feet, and finally reaches the body ; 
it is accompanied by swelling and itching last- 
ing two or three days. Then conies desquama- 
tion which is f urfuraceous and which may last 
ten to fifteen days. 

No eruption or desquamation ever occurs in 
Yellow Fever. Prof. Jaccoud has observed 
several cases of erythema of the scrotum 011 the 
first day, in several cases, during an epidemic 
in Montevideo, I believe. I have often sought 
in New Orleans this scrotal irritation without 
ever having found it. 

Dengue always gets well. It is a disease 
which does not cause tears to flow. Such is 



142 Yellow Fever. 

not the case, alas, with Yellow Fever, even 
(hiring the mildest epidemics. 

Apart, then, from a similarity of symptoms 
during the first hours only, the two diseases 
can be so well differentiated that it is only the 
absence of a clear knowledge of the symp- 
toms of Yellow Fever and of the evolution of 
Dengue which could cause hesitation in the 
clinical diagnosis after twenty-four hours. I 
put aside the commercial diagnosis, which is 
still more easily made. 

Finally, albuminuria is very rare in Dengue, 
and icterus and black vomit unknown. 

The making of a diagnostic label of Yellow 
Fever is very easy; what is difficult is the 
diagnosis of the patient, the true appreciation 
of the symptoms and of the lesions which so 
rapidly follow one another during the struggle 
between the microbe and the organism. I shall 
consider this in the chapter on prognosis. 



CHAPTER VI. 



PROGNOSIS OF YELLOW FEVER. 



During a Yellow Fever epidemic the prog- 
nosis is ruled by what may be termed the 
genius of the epidemic, for all epidemics of 
Yellow Fever are not of equal virulence. 

There are epidemics in which all persons 
attacked are seriously ill or die. There are 
epidemics of medium intensity in which the 
progress of the disease is limited and the mor- 
tality low. Finally, there are mild epidemics 
in which nearly all patients recover. 

These striking differences are due only to the 
comparative virulence of the bacillus icteroides 
and the comparative attenuation of its toxin. 

The Yellow Fever epidemic of 1853 was the 
most serious and the most fatal which ever 
visited New Orleans. Owing to the enormous 
exodus which had taken place, the population 
of the city was reduced to 45,000 or 50,000, of 
which 15,000 were negroes, besides the accli- 
mated. The mortality was 7849. 



143 



144 Yellow Fever. 

Distinguished physicians who practised dur- 
ing this terrible epidemic asserted that thev 
lost at least five patients in six. 

In 1897 we had the mildest and most be- 
nign of epidemics. The mortality was 298, 
yet, according to my statistics, which are not 
official, although as carefully taken as possi- 
ble, there were more than 6000 cases of Yellow 
Fever, hence : 

• 1853 — 5 deaths to 6 patients, mortalitv, 85 
per cent. 

1897 — 1 death to 200 patients, mortality, 
y 2 per cent. 

The organism of patients was the same in 
1 89 7 as in 1853. It must be that the bacillus 
icteroides was excessively virulent in 1S53 and 
its toxin much attenuated in 1897. 

I think I have discovered the law governing 
these differences. It is this remarkable diver- 
gence in the mortality which constitutes the 
genius of the epidemic. 

I have seen in Xew Orleans two great epi- 
demics of Yellow Fever — in 1867 and 1878; 
two epidemics of medium intensity — in 1870 
and 1873, and five mild epidemics. 

In 1867 I lost an average of 1 patient in 3. 

In 1S70 I lost an average of 1 patient in 14. 



Prognosis of Yellow Fever. 145 

In 1873 I lost an average of 1 patient in 13. 

In 1878 I lost an average of 1 adult in 29 
and 1 child in 52. 

In 1897 I treated 76 patients — 33 adults and 
adolescents and 43 children under 14, without 
a single death. 

These differences of mortality are due to the 
virulence of the microbe, or to its attenuation, 
as it is perfectly clear that, granted that a well 
conducted treatment is able to diminish the 
mortal ity, it certainly can not diminish it to 
the extent of changing the average of one 
death in three patients to that of no deaths in 
seventy-six patients ! Yellow Fever is gener- 
ally thought to be an insatiable ogre, seeking 
to devour all. What an error ! It does not 
spread at once nor does it become as rapidly 
epidemic as Influenza, Dengue, Cholera or the 
Plague. In New Orleans, where it is always 
due to importation, it invariably takes a long 
time after the introduction of the first cases to 
form its foci and to propagate itself. In study- 
ing the official documents giving the history 
of thirty-two epidemics of Yellow Fever which 
occurred in New Orleans during fifty years, 
from 1847 to 1897, I think I have discovered 
two important laws from the standpoint of 



146 Yellow Fever. 

the virulence of the disease, from that of its 
development, and from the standpoint of the 
measures necessary to prevent the propagation 
of this terrible scourge. These laws have 
constantly held good during the last thirty- 
three epidemics: 

First Law. — All. the great epidemics, as well 
as those of medium intensity, which ravaged 
New Orleans have always begun in May, June 
or July, and it has taken one, two, or two and 
a half months of incubation, after the importa- 
tion of the first case or cases, before the disease 
became epidemic or claimed many victims. 

Second Law. — All epidemics beginning in 
August or September have been mild, have 
lacked virulence, and have shown a light mor- 
tality. 

The first case of Yellow Fever in 1853 was 
declared on Ma} T 22. There were two deaths 
in May ; thirty-one deaths in June ; in July 
the disease became epidemic, one month and a 
half after the first case; the mortality during the 
epidemic was 7849. 

Epidemic of 1858 : 1 death on January 10; 
2 deaths in June; 132 deaths in July; the 
disease became epidemic in August, six months 



Prognosis of Yellow Fever. 147 

after the first case; the mortality during 1858 
was 4845. 

Epidemic of 1867: first death on June 10; 
11 deaths in July ; 255 deaths in August; the 
disease became epidemic two months after the 
first case ; the mortality for 1867 was 3107. 

Epidemic of 1878 : 2 deaths on Ma}' 22 ; not 
a single death in June ; 50 deaths in July ; by 
August Yellow Fever was epidemic, two 
months and a half after the first case ; the 
mortality for 1878 was 4056. 

Epidemic of 1847 : mortality, 2359 ; incuba- 
tion one month. 

Epidemic of 1854: mortalit} T , 2425 ; incuba- 
tion one month and a half. 

Epidemic of 1855 : mortality, 2670; incuba- 
tion one month and a half. 

The epidemics of medium intensity in 1848, 
1849, T 85o, 1852, 1857, 1870, 1873 took from 
a month and a half to two months to form 
their foci. 

As far as the second law is concerned, all 
epidemics, the first cases of which have been 
imported in August or September, have always 
been very mild, the following figures show it, 
110 explanation or comment being necessary : 



148 Yellow Fever. 

Epidemic of 1866: first case, August 10; 
total mortality, 185. 

Epidemic of 187 1 : first case, Jul}' 30; mor- 
tality, 54. 

Epidemic of - 1875 : first case, August 8 
total mortality, 61. 

Epidemic of 1874 : first case, August 19 
total mortality, 11. 

Epidemic of 1872 : first case, August 28 
total mortality, 39. 

Epidemic of 1897 : first case, September 6 
total mortality, 298. 

In 1897, ine fi rs t patient died September 6, 
and came from Ocean Springs. It was not one 
or two patients who imported the disease as in 
the anterior epidemics. Yellow Fever of such 
mild type existed in Ocean Springs that it was 
long before the physicians diagnosed it. The 
disease once officially declared, eleven or twelve 
hundred people who were summering at Ocean 
Springs and infected surroundings returned at 
once to New Orleans with their trunks, their 
belongings, and mail}' during the period of in- 
cubation of the disease in order to avoid quar- 
antine. Foci were formed in all parts of the 
city ; the disease spread at first by direct con- 
tagion, then by foci in October and November, 



Prognosis of Yellow Fever. 149 

owing to a pronounced hot spell, but the viru- 
lence of the bacillus icteroides was so feeble, 
owing to the tardy importation, that the mor- 
tality was only one in two hundred. 

The history of the last thirty-three epidem- 
ics proves that an important part is played by 
the month in which is made the importation 
of the first cases, and that the pathogenic bacil- 
lus increases in virulence mainly during the 
three hottest months — June, July and August. 

Yellow Fever is certainly contagious, even 
very contagious under certain circumstances, 
as, for instance, on a ship or in a small village. 

All microbian diseases are more or less con- 
tagious. A patient . with Yellow Fever may 
communicate, and often does communicate, the 
disease to a person nursing him, one living in 
his room, living in the same house or the ad- 
joining one, as I have seen in many instances, 
but is Yellow Fever communicable only by 
direct contagion ? The bacillus icteroides is 
cultivated in swarms in the human body, but 
is the human body its only field of culture ? 

The great epidemics which have ravaged 
New Orleans can not be explained in their de- 
velopment simply by the culture and growth 
of the microbe in the human body alone. 



150 Yellow Fever. 

In 1878, for example, a patient died of Yellow 
Fever in the month of Ma) T — bear well in mind, 
during the month of May. The corpse was 
buried in a walled-up tomb ; even did the patho- 
genic microbes continue to multiply after death, 
they had no means of exit in order to propa- 
gate themselves outside or to create an epi- 
demic. During the rest of May and in June, 
no other point infected by the disease was 
found ; yet, during July and August it broke 
out and in three months had infected twenty 
to twenty-five thousand persons and killed 
4056. 

The histor3 T of Yellow Fever in 1878, like 
that of the other great epidemics which de- 
clared themselves onl}^ one to two months after 
the first and always imported cases, seems to 
prove, by the long incubation of the germs, 
that the microbes which give rise to the epi- 
demic one or two months after the burial of 
the first victims do not come from the bodies 
of the first patients. 

Sanarelli has found the bacillus icter- 
oides in the trachea and in the bronchi ; Dr. 
Archinard, in the case of several patients, has 
found it in the expired air. 

Be it by means of the expired air, by the 



Prognosis of Yellow Fever. 151 

dejections, by the secretions, by the perspira- 
tion, or bv the contaminated clothing of the 
patients, that the pathogenic microbe is planted, 
it is at any rate outside of the patient. 

A culture surely can not grow and prosper 
in the air, in clothing, on the walls of houses, 
nor on the floor of a room. It is probably in 
the muddy streets ; in the offensive gutters, 
wetted bv rains * and heated bv the burning 
sun that this pathogenic vegetable growth 
must find the best surroundings for abundant 
food in order to multiply and increase its 
virulence by successive cultures ; suspended in 
the air, deposited in certain foci, where it 
develops at a given time, it produces an epi- 
demic. 

Under such conditions Yellow Fever would 
not be contagious only through the patient, but 
also by means of foci ; this might explain the 
pronounced divergence of opinion of the physi- 
cians of the last centurv and the beginning of 
this, who were divided into two camps, the con- 
tagionist and the non-contagionist. 

Xo matter how incontestable and frequent 
are the instances of direct contagion, a Yellow 

*In June. 1S53. there were downpours of rain twenty-, 
three davs out of thirtv. 



152 Yellow Fever. 

Fever patient giving the disease to a healthy 
person living, if I may so express it, in the 
same air, the instances of persons who have 
never approached a patient sick with Yellow 
Fever and who have taken the disease in the 
street or in an infected place are perhaps still 
more numerous. How frequently patients fail 
to communicate the disease to their family or 
those about them. 

At the hospital of the French Societv, where 
over 1000 cases of Yellow Fever have been 
treated by me, I have never observed one case 
starting from within. In 1867 I had five male 
nurses, of whom three were non-acclimated ; 
all remained free from the disease. 

Yellow Fever is contagious, but in my 
humble opinion the contagion is not only 
directly from the sick to the healthy; dur- 
ing an epidemic, a large number of patients 
take the disease within foci outside of the 
human body in which the bacilli have de- 
veloped, multiplied and acquired virulence. 

The same thing is true of Yellow Fever as 
of typhoid, which may be said to be contagious 
also, but is propagated especially by drinking 
contaminated water. The valuable works of 
Professor Chantemesse have proved and demon- 



Prognosis of Yellow Fever. 153 

strated that it is absolutely necessary to prohibit 
the use of river or well water polluted by 
Eberth's bacilli in order to arrest an epidemic 
of typhoid fever. 

How man}- human lives have been saved 
since the habitat of the pathogenic bacillus of 
typhoid fever is known ! 

From a sanitary standpoint, the knowledge of 
the habitat of the pathogenic bacillus of Yellow 
Fever and of its field of culture outside of the 
patient, will prove of the greatest importance. 

The bacillus discovered by Sanarelli seems 
to be the pathogenic microbe of Yellow Fever. 
It should be planted in ground and subjected 
to similar conditions of humidity and heat as 
the mud of streets, in order to know if it grows 
in that manner. Should there be future epi- 
demics, it must be sought and isolated in the 
mud of drains, in the dust of the streets and of 
the air, in order to determine the dens of this 
terrible enemy. 

From the results of these experiments, diffi- 
cult of execution I admit, may flow the indica- 
tions most efficient to rid us of the terrible 
scourge. 

Sanarelli has studied the favorable influence 
of mould on the development of the bacillus 



i54 Yellow Fever. 

icteroides. " I have seen on several occasions," 
savs lie, " gelatin remain sterile after the im- 
plantation of the bacillus icteroides at the same 
time that agar sown simultaneously showed a 
growth. 

" However, if some mould reached it in time 
and developed its inycelium, there appeared 
immediately around the latter, in the gelatin, 
a ring of small punctiform colonies of bacillus 
icteroides. 

" This strange parasitical phenomenon may 
be the cause of the easy acclimation of Yellow 
Fever on shipboard where moist heat and the 
lack of ventilation favor the development of 
mould, the latter being indirectly favorable to 
the vitality of the bacillus icteroides." 

The most vigilant efforts must be continued 
in order to prevent the entrance of Yellow 
Fever, but if it entered notwithstanding, we 
would still be doing good work if we could 
prevent it from multiplying and propagating 
by knowing the law of the development of its 
bacillus. 

The da}' that we know how and where the 
germs of Yellow Fever develop outside of the 
patient, a great advance will have been made 
in protective sanitation. 



Prognosis of Yellow Fever 



oo 



The most urgent measures for the preven- 
tion of Yellow Fever appear to be the paving 
of our streets, the establishment of a good 
system of drainage and sewerage, the cleanli- 
ness of our gutters, and the supply to our 
people of a better water than that now fur- 
nished by the Waterworks Company, which 
is meat as well as drink. 

By means of this improvement, Xew York 
and Philadelphia have become rid of the Yel- 
low Minotaur. Yet, communication between 
those cities and countries where Yellow Fever 
reigns endemically are more frequent to-day 
than formerly. 

Yera Cruz, which was formerly a frightful 
nest of typhus icteroides, is to-day in sanitary 
condition, owino- to the establishment of sew- 
erage, the supply of pure water to its inhabi- 
tants, and the cleanliness of its streets. 

A study of the last thirty-three epidemics 
teaches the positive conviction that the first 
imported cases do not directly produce epi- 
demics, but carry the seed. It is the icteroid 
bacilli escaping from the . first patient, carried 
perhaps in his clothing on shipboard, which, 
once implanted, prosper outside of the body in 
a favorable culture medium ; the latter, I am 



156 Yellow Fever. 

aware, is unknown ; it might well be the 
damp mud overheated by the sun, in our 
unpaved streets and our gutters, which are 
always choked with moist and decomposing 
vegetation. 

All the very serious epidemics, those having 
caused disastrous results in New Orleans 
within fifty years, have commenced by one or 
two cases of Yellow Fever imported in Alav or 
June ; only after an intermission of eight to 
ten weeks has the germ multiplied sufficiently, 
outside of the human body, to produce the 
twelve great epidemics during which were 
infected nearly all persons not immunized by 
a previous attack. 

When Yellow Fever is imported in August 
or September it does not find the same condi- 
tions of moisture, sunshine, hot nights, etc., 
so favorable to its pathogenic microbes. The 
latter must find the culture media bad, for it 
does not become virulent ; all epidemics due 
to tardy importation have been very mild. 

I hope the reader will pardon the length}' 
details into which I have entered, owing to the 
importance of the subject just considered. 

The two great factors in prognosis are, then : 
1. The genius of the epidemic — that is, the 



Prognosis of Yellow Fever. 157 

greater or lesser virulence of the germ. 2. 
The organic resistance of the patient. 

As has already been said, age, alcoholism, 
excesses, bad habits, insufficient food, unsan- 
itary lodging, emotions, fright, excessive work, 
and the lack of care, influence greatly the 
course and the termination of the disease. 

The younger, the healthier, the stronger 
the patient, the greater his chances of recovery. 

The genius of the epidemic and the consti- 
tutional condition of the patient furnish gen- 
eral ideas concerning prognosis, but it must be 
enlightened in each individual case of Yellow 
Fever by an appreciation of the symptoms and 
of the organic functions and lesions presented. 

To prognosticate correctly, the physician 
must at each visit make a minute search and a 
careful review of all the symptoms, but the 
valuable symptom, the beacon, the true guide 
during the first three days of the disease, is 
the fever, the course and the degree of tem- 
perature. 

When the fever reaches its maximum at the 
outset and defervescence is continuously noted 
at each visit, the disease is mild. 

When the fever ranges between 103 and 
104.5 deg. e ven during the first three days, with 



158 Yellow Fever. 

remissions of at least a degree in the morning 
and the exacerbations are less and less pro- 
nounced each night, the patient always gets 
well. 

When the fever ranges between 104 and 105 
cleg., still with remissions of at least a degree, 
but with exacerbations above the degree of 
fever of the day previous, the disease is to be 
considered grave, yet the cases of recovery are 
more numerous than the fatal ones. 

When the fever reaches 105 deg. or above 
within the first twelve hours, Yellow Fever is 
nearly always fatal unless heroic treatment 
immediately produces a defervescence of two 
or three degrees. 

When defervescence is not maintained after 
the temperature has reached 105 deg. or above, 
and the fever again rises to the same point, 
death is almost certain ; a temperature above 
105 deg. during the first twenty-four hours 
gives slight hope of recovery in adults. 

Copious urine is always of good augury even 
should it contain five or ten per cent, of albumin. 
A patient who urinates in abundance nearly 
always recovers, although there are rare ex- 
ceptions. 



Prognosis of Yellow Fever. 159 

Scanty urine, with twenty or twenty-five per 
cent, of albumin on the second day, accom- 
panying a fever above 104 deg., indicates great 
danger. 

When the urine forms a complete coagulum 
on being heated, death is certain. 

When anuria lasts twelve hours, death is 
absolutely certain. I have seen patients recover 
after having had the most serious symptoms, 
but I have never seen it occur when anuria 
existed. Anuria is the death warrant, not sub- 
ject to appeal. 

Icterus indicates gravity in greater or lesser 
degree, according to the time at which it ap- 
pears. 

Intense icterus on the third day, urine scanty 
and albuminous, black vomit occurring at the 
same time, form a group of symptoms an- 
nouncing death. 

Black vomit on the third day is nearly 
always fatal. 

Black vomit on the fourth day, when accom- 
panied by a rapid fall in temperature, is also 
nearly always fatal. 

When, black vomit having occurred, the 
fever does not fall suddenly, the temperature 
continuing to range between 101 and 103 deg., 



160 Yellow Fever. 

the situation is very serious, but there is still 
some hope of recovery. 

The later the occurrence of black vomit, on 
the fifth or sixth day, the greater the chance of 
recovery, although yet slight. The more abun- 
dant and repeated is the black vomit, the more 
serious the condition. 

Black vomit is less grave in children and in 
young women than in adults, particularly those 
having reached over forty years of age ; the 
latter always die. 

Incoercible vomiting at the outset is a very 
bad symptom, and uremic vomiting is nearly 
always followed by death. 

Profuse bleeding of the gums, coming before 
or at the same time as black vomit, indicates 
an almost desperate state. 

Should black vomit occur only on the fourth 
or fifth day, the gums being sound, the prog- 
nosis is less gloomy. 

Intestinal hemorrhage is always very dan- 
gerous, and the occurrence of evacuations of 
gangrenous odor is always followed by death. 

Women having uterine hemorrhage on the 
fourth and fifth days with black vomit never 
recover. 



Prognosis of Yellow Fever. 161 

The three principal prognostic indications 
can be resumed as follows : 

i. The degree of the temperature. 

2. The urinary secretion, quantity and qual- 
ity. 

3. Hemorrhage, especially from the stom- 
ach. 

Yellow Fever is a disease of surprises occa- 
sionally, though not frequently, leading astray 
the most vast experience. Patients die whose 
recovery had been announced, and, -per contra, 
some patients given up to die appeal from the 
decision of the physician. 

As a rule, the physician must be very cau- 
tious in his prognosis. 

In 1867, I was treating some workmen in a 
boarding house; the proprietor had requested 
to be advised as soon as I was positive a 
patient would die, as he desired to take him to 
the hospital, in order to avoid his dying in the 
house and impressing the other patients. 

One night I pointed out a patient whom I 
believed to be nearing his end. On the mor- 
row I was surprised to find the patient in bed, 
seeming much better. I was told that the 
night before, while having abundant black 
vomit every few minutes, he had risen in his 



1 62 Yellow Fever. 

delirium and had swallowed at one draught a 
basin half full of dirty water, in which all the 
healthy workmen had washed their hands. 
The patient had vomited a part of this disgust- 
ing, soapy water and also had been purged to 
excess, but the black vomit had been arrested 
and, three days later, the resuscitated one 
entered into convalescence. 

Another patient had been placed in a car- 
riage to be taken to the hospital to die. Pass- 
ing a barroom, his landlord conceived the idea 
of offering the moribund a last glass of whis- 
key, of which drink he had been very fond in 
health. The bottle was brought out to the 
patient, who half emptied it. This enormous 
dose of alcohol arrested the black vomit, 
boosted up the man, who recovered, to my 
great surprise. 

These two instances are mentioned, not in 
order to encourage resort to extraordinary 
treatment, but to prove that the most des- 
perate cases sometimes can recover, and to 
encourage the physician in struggling for the 
life of his patient up to the time of death itself. 

A patient must never be given up! 



CHAPTER VII. 



TREATMENT OF YELLOW FEVER. 



There is as yet for the cure of Yellow Fever 
no sovereign or specific remedy as we have for 
Malaria, in quinin ; for Syphilis, in mercury 
and iodide of potassium ; for Acute Articular 
Rheumatism, in salicylate of soda ; for Diph- 
theria, in antitoxin. 

However, we are well armed and prepared to 
aid the organism in its struggle against the 
icteroid toxin, to attenuate its effects, to retard 
or prevent cellular lesions, to dilute and es- 
pecially to eliminate the poison. 

All the means we possess to secure the cure 
of the patient, or at least to try and bring it 
about, constitute the medication of Yellow 
Fever. 

It is the medication of Yellow Fever such as 
I understand and practice it that I shall ex- 
pose in this chapter. I shall go into details 
which may appear minute, but I believe them 

163 



164 Yellow Fkvkr. 

to be very useful as, when treating a patient 
attacked by any disease whatsoever, it is good 
to remember a saying of my preceptor Trous- 
seau : " To cure, there are no small measures." 
Guy Patin, full of malice and humor, relates 
that during childhood Louis XIV had measles 
and it required six or eight venesections to 
save from the clutches of death the one who 
was to be the Grand Roi. 

Upon reading accounts of the treatment of 
Yellow Fever during the last century and in 
this, almost up to our day, it is seen that the 
measures employed in the treatment of this 
terrible disease were repeated purgatives, suc- 
cessive emetics, copious bleeding, wet cupping, 
blisters, powdered cinchona in massive doses, 
and, later, sulphate of quinin in large propor- 
tions. 

Long ago, all active medication, particularly 
venesection, was laid aside in the treatment of 
eruptive fevers, and rest, aeration of the sick 
room, the administration of warm drinks in 
abundance and of liquid food, such as milk 
and thin broth, now constitute the therapeusis 
of these infectious diseases. 

It has taken centuries for the cry of distress 
of the organism to be heard ! " The Lord save 



Treatment of Yellow Fever. i6 ; 



me from my friends, I can take care of my 
enemies ! " 

Since Pasteur has taught us the pathogeny 
of infectious diseases, and since we have learned 
that no remedy has a direct and salutary effect 
on any microbe known to us or its toxin, we 
load and irritate the stomach less and less with 
remedies. " Drugs are dying out." The treat- 
ment of Yellow Fever, just as that of the erup- 
tive fevers and of Typhoid Fever, as well as 
all infectious diseases, tends to rid itself from 
day to day of remedies that are nearly always 
useless when thev are not harmful. 

Professor Bouchard has furnished to physi- 
cians the most important therapeutic indication 
in the efficient treatment of infectious pyrexias 
by his studies on the toxic properties of urine 
in infectious diseases, on the renal elimination 
of toxins, and on organic filtration by the urine. 

The sovereign remedy in Yellow Fever will 
be the antitoxin whose discovery is announced 
by Sanarelli. As soon as it is at our disposal, 
we shall certainly be relieved of the enormous 
mortality of Typhus Icteroides in time of epi- 
demics especially if, as is the case with Roux' 
serum, it is both immunizing and curative. 

While awaiting a practical realization of the 



1 66 Yellow Fever. 

great discovery, we are not entirely powerless, 
and can, by means of a well-conducted method 
of medication, meet the two principal indica- 
tions of treatment in Yellow Fever, as follows : 

i. To strengthen and sustain the organism 
by fortifying the nervous system, by arresting 
congestion, and by increasing blood pressure 
and diuresis. 

2. To consume, destroy and eliminate the 
toxin. 

The first indication is fulfilled by means of 
cold sponging, by cold baths administered, not 
in a systematic or routine way, but by taking 
the virulence of the disease and the degree of 
fever as guides. 

The second indication is met by putting the 
patient in a well aerated room night and day, 
and by making him drink, in order to cleanse 
his blood, dilute the toxins, and eliminate them 
by way of the urine, two, three or four quarts of 
Vichy water (Celestins) in twenty-four hours. 

The treatment of Yellow Fever is very diffi- 
cult from the fact that the disease, like Chol- 
era and the Plague, frequently has a very acute 
and very rapid course, and that in very viru- 
lent cases the physician has really only a few 
hours in which to act with efficacy. 



Treatment of Yellow Fever. 167 

At the outset of the infection the patient can 
be succored, but what can be done when the 
organism is poisoned, when the toxin has 
already affected the hepatic cells and the renal 
parenchyma, and when the mucous membranes 
are bleeding? The physician is practically 
disarmed, for such lesions are nearly always 
fatal. 

It is during the first three days of the disease 
that the physician must act. When black 
vomit has come to darken the situation, we can 
yet save some patients, but we are much better 
prepared to prevent the occurrence of black 
vomit than to cure it. 

The first and the most indispensable thing 
for success in the treatment of Yellow Fever is 
that it be begun as soon as the disease has 
declared itself. 

When confronting a patient attacked by 
Yellow Fever, what must be done? 

Medication of Yellow Fever. 

1. Absolute Rest of the Patient. — The 
first thing is to put the patient to bed. Rest 
is essential and indispensable. The patient must 
not be allowed to rise either during the period 



1 68 Yellow Fever. 

of congestion, during the conrse of the disease, 
or during convalescence. Great strictness and 
severity are necessary on this point. I allow 
a patient to rise only after the fever has ceased 
since several days, after he has begnn to 
nourish and to recuperate his strength, but 
never before the pulse, slowed by convalesence, 
has become of normal frequency for at least 
two days. 

Walking, moving, the least muscular effort, 
always increase the fever and consequent!}' 
the gravity of the disease. How many times 
have I observed the truth of this statement ! 

An increase of a quarter or a half degree 
has no great importance when the temperature 
ranges between 102 and 103 deg. ; but when the 
temperature is between 104 and 105 deg., a rise 
of half a degree, provoked by imprudent move- 
ments, ma}' be very serious and lead to the 
patient's death. I can not count the number 
of patients whom I have seen die, in this 
manner, by their own fault. It is even neces- 
sary for complete security that patients should 
make no muscular efforts, and that the nurses 
should turn them, change their position, put 
them on the bedpan, etc. Rest must be absolute 
both during the disease and the convalescence. 



Treatment of Yellow Fever. 169 

In 1897, two physicians died of Yellow 
Fever; both had at the outset such a light 
attack that they continued to make their pro- 
fessional calls. As usual, the disease from 
mild became serious on this account, and both 
paid with their lives for their courageous im- 
prudence. 

Relapses, which are always much more viru- 
lent than the primary attack, most frequently 
occur because the patient gets up or eats too 
soon. 

2. Aeration of the Room. — The patient 
must be placed in the largest and best vent- 
ilated room in the house, exposed to the 
rising sun, if possible. The Spanish proverb 
can be quoted in reference to Yellow Fever : 
" Where air and sunlight enter not, death 
enters." 

Open the windows wide, night and day. Do 
not place the patient in a draft, but let the out- 
side air enter, circulate freely, and be renewed 
constantly. 

In Yellow Fever, as in all infectious diseases, 
pure air is absolutely necessary, indispensable, 
the best remedy, one without which we can not 
do. The inspiration of pure air by the patient 
twenty-five or thirty times a minute cools his 



170 Yellow Fever. 

blood, charges his corpuscles with a normal 
quantity of oxygen; this thorough oxygena- 
tion of the blood hastens the phenomena of 
nutrition, and especially the oxidation of the 
toxin. Pure air is the best auxiliary of the 
cells in aiding them to get rid of the icteroid 
virus. This is so true that in all epidemics 
the mortality is excessive among badly lodged 
patients living in wretched holes where the air 
is unrespirable. 

Emigrants and new arrivals, even when 
young, strong, well-built and temperate, are 
decimated because their lodgings are poor, 
unsaxiitary, bad smelling and overcrowded. 

The Italians who, together with the drunk- 
ards, furnished nearly the total mortality of 
the last epidemic, died not because they were 
Italian, but because they were ill in miserable 
quarters, of which one can scarcely have an 
idea, and lacked all care. 

Such Augean stables must be made to dis- 
appear in cities liable to visits from Yellow 
Jack, and the question of unsanitary lodgings 
must be one of the first to receive the atten- 
tion of a Board of Health knowing its busi- 
ness and duty. Upon the first appearance of 
Yellow Fever, they should cause without 



Treatment of Yellow Fever. 171 

delay the evacuation of all these centres of 
pestilence and death. 

In 1867, two confreres and I treated a num- 
ber of Italians in a large hovel, whose rooms 
were ill-ventilated, and in which were crowded 
men, animals, and decomposing fruit. Of 
thirty-seven patients, thirty-six died. 

Unfortunately, popular prejudice is against 
the aeration of the sick room, especially at 
night, the physician often being asked if the 
dew is not to be dreaded. Be firm in combat- 
ing with conviction, with eloquence and all 
your authority, a prejudice which makes too 
many victims. 

During each epidemic I have seen many 
children killed by ignorant mothers, who in- 
sisted upon keeping them in tightly closed 
rooms in which the air was never renewed and 
five or six persons were consuming what little 
oxygen there was ! 

Tell the parents to open wide the windows 
and doors and to allow the windows to remain 
open night and day. Air, air, always air ! 

Too often, the physician once gone, the win- 
dows are closed and the patient once more be- 
comes deprived of pure air, much to his detri- 
ment. 



172 Ykllow Fever . 

3. Clinical Observations. — Once the pa- 
tient is placed at absolute rest in a well aerated 
room, I take the following clinical notes : The 
exact hour of the outset of the disease ; the 
condition of the stomach, of the intestines, and 
of the mind ; I then count the pulse, take the 
temperature and mark the results on a clinical 
chart. 

4. Recommendations to the Nurse. — 
The patient must be kept very clean; should 
he be soiled by evacuations, vomiting, or epis- 
taxis, change the linen and plunge the soiled 
objects at once into a large tub containing an 
antiseptic, preferably bichloride of mercury, 
one gramme to a bucketful of water. Cleanse 
the patient's mouth and teeth twice a day with 
warm water and a tooth brush sprinkled with 
powdered bicarbonate of soda. Administer 
every morning and night, by enema, a pint of 
warm water containing a tablespoonful of sul- 
phate of soda or magnesia. The cleansing of 
the mouth and the bowel must be done daily 
during the entire duration of the disease, unless 
countermanded. 

A well cleansed mouth is a comfort to the 
patient, often prevents the swelling and 
bleeding of the gums, and diminishes the 



Treatment of Yellow Fever. 173 

danger of secondary infections leading to the 
production of parotiditis. 

The regular administration of enemata keeps 
the bowels free and also diminishes the chances 
of secondary intoxication by way of the intes- 
tine. The patient always feels better after 
evacuating an enema. 

5. The Urine — My last recommendation is 
that the nrine voided in twenty-four hours be 
put aside, in one vessel as far as possible. 

At each visit I have the vessel brought to 
me and can judge, by that means, of the 
proper or improper functioning of the kidneys. 

The execution of these recommendations 
must be watched during the entire course of 
the disease. Once they are well understood 
and appreciated the treatment can be begun. 

Treatment of the Period of Congestion 
and During the Course of the 
Disease. 

Calomel. — I give, according to age, two or 
three grains of calomel, two grains to adol- 
escents, three grains to adults ; to children I 
give even only one grain. 

I give it more as an intestinal antiseptic 



i;4 Yellow Fever. 

than as a purgative, and administer it in such 
small doses in order not to overpurge the 
patient and especially not to irritate the 
stomach or the bowels. 

Rarely do I repeat the calomel unless there 
be pressing indications, as the large enemata, 
administered night and morning, keep the 
bowels in good condition without producing 
any irritation of the digestive tract. If the 
calomel is vomited, however, it would be better 
to repeat the dose once the stomach becomes at 
rest. 

Foot Bath a la Creole. — In New Orleans, 
when the physician makes his first visit he 
finds that the patient has already been given a 
Creole foot bath. If it has not been done, you 
must order one, and if it is not known how to 
give it, here is how you must proceed : half 
fill a foot-tub with rather warm water, adding 
a pound of freshly ground mustard which 
must first be dissolved in sufficient cold water ; 
place the foot-tub in the bed ; the patient's feet 
and legs, the latter being flexed while the 
patient remains on his back, are then plunged 
in the water. 

The patient and the tub both are covered 
with two or three woolen blankets and, the lat- 



Treatment of Yellow Fever. 



75 



ter being lifted, a pint or two of very hot and 
almost boiling water are added to the bath 
every three or four minutes. 

The bath must be very hot; while it must 
not burn the feet, it is necessary that the heat 
and the mustard produce a powerful revulsive 
effect, which the patient must bear until the 
pain becomes too severe. 

The patient is given a vapor bath under the 
cover; it causes him to sweat freely, his face 
and entire body being covered with perspira- 
tion; during eight or ten minutes this sudo- 
rific effect must be kept up by continuing to 
add hot water to the bath and by the drinking 
of hot aromatic infusions. 

Properly given, the foot bath produces pro- 
fuse diaphoresis; a marked and favorable 
relaxation occurs and the phenomena of con- 
gestion are controlled. Cephalalgia and rach- 
ialgia seem to disappear. I had occasion to 
appreciate the good effect of the foot bath and, 
since 1866, 1 have always ordered it at the out- 
set of the disease, and have always had occa- 
sion to congratulate myself upon the result. 

Should the physician. deem it necessary, the 
patient being very plethoric and the phe- 
nomena of congestion much accentuated, the 



1 76 Yellow Fever. 

foot bath can be renewed two or three times 
during the first twenty-four hours of Yellow 
Fever. 

When the revulsion has become painful and 
unbearable, a profuse sweating having been 
obtained, the foot-tub is to be withdrawn and 
the patient allowed to perspire about fifteen 
minutes or more, still covered with the two or 
three blankets. 

The patient must then be quickly and thor- 
oughly dried. The moist sheets and blankets 
must be removed, and a light woolen blanket 
must be slipped under the patient and wrapped 
around him. He is to be left, during the first 
three days, without night-shirt or any clothing 
whatever, in order that he may not be fatigued 
by being dressed and undressed when he is 
sponged. 

Cold Spoxgixg. — After this, I give in per- 
son a cold sponging to the patient. I act as 
nurse in this wise in order that the patient may 
have the best chance for proper treatment ; for, 
if you do not teach these things yourself, you 
are only half understood and your orders are 
imperfectly executed. A badly applied spong- 
ing does no good and gives no result. Many 
times have I seen patients remain in the same 



Treatment of Yellow Fever. 177 

state or get worse because the persons nursing 
them did not get my orders straight. 

Always watch your patient, but watch also 
the purse.* This is the advice of an old clin- 
ician. In a disease like Yellow Fever the 
active treatment of which is so short, every 
detail must be carefully worked out. 

To give a good sponging it is necessary to 
use a large bucket containing four or five gal- 
lons of cold water. This bucket is to be 
placed on a stool or chair near the patient's 
bedside. Do not use a sponge, but take a 
large, soft towel, a little the worse for wear; 
dip it completely in the water ; wring it 
slightly, in order that the water may not drip 
from it, and, uncovering the patient, sponge 
him by rubbing gently the chest, the abdomen, 
the thighs, the legs and the feet, wetting the 
towel with cold water from time to time ; con- 
tinue the sponging until the little operation 
has been repeated ten or fifteen times if neces- 
sary. The most important point is not to 
cease sponging before the wet tov^el is no 
longer heated by the patient, before it no 
longer abstracts heat, or before the patient's 

*This does not apply to trained nurses; but, unfortunately 
every one can not have a trained nurse during an epidemic. 



1 78 Yellow Fever. 

skin is to the touch of the same temperature 
as the cold water. 

The patient must then be quickly wiped 
with a dry towel and turned on his stomach, 
in order that the sponging, with the same 
care, be applied to the posterior part of the 
thorax, to the back, the nates, and the lower 
limbs. Having dried these parts in turn, the 
upper extremities must also be sponged, after 
which the face and head must be sponged in 
turn with ice water. All this terminated, the 
patient is to be wrapped in his light woolen 
blanket. 

It can not be imagined how much comfort 
and ease are produced by this careful spong- 
ing. By this means my temperature was 
moderated when I had Yellow Fever in 1866. 
To this I owe my recovery, and, since that 
time, I have always sponged my patients. 

After a well applied and thorough sponging, 
the temperature falls one or two degrees. The 
painful phenomena due to congestion of the 
head, the stomach and back, disappear as if by 
magic. The patient thinks himself cured. 
Unhappily, the surprisingly beneficial effects 
are not of long duration, and the process must 
be repeated and continued. I follow this rule: 



Treatment of Yellow Fever. 179 

guided entirely by the degree of fever, if 
the patient's temperature does not reach 
above 103 deg. I have him sponged every two 
hours; should the fever range between 103 
and 104 deg., I have the sponging done every 
hour; if the fever ranges between 104 and 105 
deg., I order spongings every half hour. I 
have the temperature taken before and after 
each sponging, as I attach great importance 
to the amount of remission produced. If 
the remission is of one degree or more, I 
consider the result favorable; if it is less 
than a degree, I act more vigorously. To 
act more vigorously is to use colder water for 
the sponging. 

Ordinarily I have the water used at its 
natural temperature, that is just as it leaves 
the cistern or hydrant. At the time of the 
year at which Yellow Fever exists, in summer 
in the United States, the temperature of the 
water varies between 75 and 85 deg. If at such 
temperature the sponging does not produce a 
remission of at least one degree, I add from 
four to six pounds of ice to the water. The 
colder the water, of course, the more heat it 
abstracts, the faster it causes contraction of the 
capillaries, the more it strengthens the vaso- 



180 Yellow Fever. 

motor system, and the more rapidly it lowers 
the fever. 

In Yellow Fever, the more elevated the 
temperature the more dangerous the case, and 
especially the more danger it indicates, conse- 
quently, the more active must the treatment 
be. I then cool the water in order to increase 
the difference between the temperature of the 
patient and that of the bath. A rapid remis- 
sion must be produced at any price and water 
at 60 deg. lowers the temperature, contracts 
the capillaries, and stimulates the nervous 
system much more rapidly than water at 85 
deg., while it also increases diuresis to a 
greater degree. The higher the fever, the 
colder must the application be ; success de- 
pends upon it. 

The first contact of the cold water on the 
burning body causes more of a surprise than 
a suffering' ; it lasts onlv a few seconds and 
the patients derive so much comfort from the 
sponging that they are the first to ask for its 
repetition when the fever rises again. 

A few patients, particularly very nervous 
women, do not bear this sudden impression of 
cold and are excited thereby. Do not insist, 
but begin the sponging with tepid water and 



Treatment of Yellow Fever. 181 

cool slowly, continuing the sponging for a 
longer time. 

In small children I prefer baths in water 
neither warm nor cold, that from which the 
chill has been taken, as the expression is — say 
about 85 deg., if the rectal temperature is not 
above 104.5 deg.; ^ u ^ ^ the rectal temperature 
is above 105 deg., I order baths cooled to 75 
deg.; children bear these baths admirably and 
derive a pronounced benefit from them. The 
fever is lowered tw 7 o or sometimes three degrees. 
The nervous excitability which is so constant in 
children with Yellow Fever is completely con- 
trolled by the baths. The sedation is remark- 
able, and the child once dried and put back to 
bed falls into a calm and peaceful sleep. 

I repeat these baths every hour, if the tem- 
perature is above 104 deg.; every two hours, if 
it is only about 103 deg., and once the fever is 
decreasing, I have them given every six to 
eight hours until the temperature becomes 
normal. 

Cold Baths. — When, in the adult, the fever 
reaches 105 deg. or above, I immediately put 
the patient in a cold bath, taking his tempera- 
ture in the mouth every five minutes. If the 
temperature is lowering regularly, I let him 



1 82 Yellow Fever. 

remain twenty to thirty minutes in the bath, 
or until I have obtained a remission of at least 
two degrees ; if the remission is produced 
too slowly, I add twenty to fifty pounds of ice 
to the bath. The physician mnst act with con- 
fidence, without dread of injuring the patient, 
for all fear is delusive, and this is the sole, 
though heroic, way of attaining recovery. 

The cold bath treatment will not save all 
patients whose temperature is above 105 deg., 
for there are cases of Yellow Fever so virulent 
that they can not be snatched from death ; but, 
if one-half can be saved, a result will have 
been reached which no other medication can 
yield. Should there be no bath tub on hand, 
the patient must then be sponged with ice 
water by two or three persons until the temper- 
ature has been brought down to 103 deg. at 
least. The cold bath is certainly preferable 
when the temperature is above 104 deg.; refrig- 
eration is more complete, and is made over the 
entire surface of the bod}' simultaneous!}' ; by 
means of ice the water can be kept at the tem- 
perature desired and lowered whenever judged 
necessary. Unfortunately, Yellow Fever in 
the ports to which it is carried is a disease 
attacking poor folks. Rich people, when 11011- 



Treatment of Yellow Fever. 183 

acclimated, go to the mountains and are not 
wrong. The poor devils have no bath tubs at 
their disposal, but can always furnish a bucket 
and cold water. 

Sponging must be resorted to night and day 
during the entire period of congestion, three 
days at least, and longer, if the fever assumes 
a remittent type which often lasts five and six 
days. The baths must be repeated also, if the 
fever rises above 105 deg., the sponging being 
sufficient if the temperature is lower. 

I need not expose at greater length the 
advantages of hydro-therapic medication, as it 
is to-day the reigning treatment of nearly all 
infectious diseases. It is resorted to in Typhoid 
Fever; in the eruptive fevers, including scar- 
latina; in acute articular rheumatism of cere- 
bral character; in the infectious algid period 
of cholera infantum, in which cases the rectal 
temperature frequently reaches above 106 
deg.; in nbrinous-piieumonia, broncho-pneu- 
monia, or grippal-pneumonia; in a word, in all 
the infectious pyrexias in which virulence is 
denoted by a very high fever. 

Results have proved the advantages of this 
medication. Brand's method has reduced the 
mortality of Typhoid Fever to 7 per cent, and 



is.) Vku.ow Fever. 

in the Bavarian army to i per cent. Louis 
used to call Typhoid Fever the opprobrium of 
medicine, owing to its mortality, which, forty 
years ago, used to be over 60 per cent. In 
pneumonia the mortality has been reduced to 
13 per cent., while it is 29 per cent, when 
treated by ordinary methods. In Yellow Fever, 
the best results are always obtained, as I shall 
not tire of repeating, when the sponging is 
done at the outset of the disease. Upon that 
is conditional its influence toward a favorable 
final result. When sponging is begun only 
on the second, or especially on the third day, 
half of the beneficial effect is lost, the results 
not being comparable to those obtained when it 
is resorted to from the first day of the disease. 

This medication meets all the indications in 
Yellow Fever ; it lowers the temperature one 
or two degrees ; it acts favorably on the heart, 
its beats becoming stronger ; it contracts the 
capillaries, diminishing congestion ; it quiets 
the nervous system ; it acts with energy on 
the vaso-motor nerves ; it increases blood 
pressure ; favors diuresis to a great extent ; 
increases the action of the skin and produces 
its antisepsis. 

Billings has shown that a cold bath increases 



Treatment of Yellow Fever. 185 

the number of leucocytes considerably, and 
that, after a bath at 75 deg. of twenty minutes- 
duration, the white corpuscles in blood taken 
from the lobe of the ear increase from 7724 
to 13,170. I have a large experience with cold 
sponging in Yellow Fever, for I have practised 
them since 1866 and have treated more than 
two thousand cases, having been ray own 
client at first. To them I certainly owe v&\ 
best successes and some unlooked-for cures. 

A properly made sponging lowers the fever, 
diminishes congestion, increases blood press- 
ure, and causes abundant urination. The 
constant and most wonderful result, however, 
is that the patient is always relieved beyond 
expression by the sedative and calming action 
on the nervous system. High fever above 
104 deg. puts the patient in a state of gen- 
eral excitability, a mental and muscular deli- 
rium, which nothing appeases like the cold 
sponging or the cold bath. Cold is the most 
pronounced sedative against pain and nervous 
excitability. We know it since the time of 
Hippocrates, but we forget it too often when 
trying to relieve the patient. 

The patients who recover are those whose 
fever remits in a marked manner, and who 



i8( Yellow Fever. 

urinate abundantly. Since cold baths are used 
in Typhoid Fever, nephritic complications are 
very rare ; long ago I noticed that albumin was 
often absent and not very pronounced in very 
serious cases, when patients were proper! v 
sponged. 

The good results of sponging are moment- 
ary, Yellow Fever being a cyclic disease which 
can not be arrested or jugulated. Spongings 
only moderate the fever and attenuate the 
symptoms, it is true, and in an hour or two 
one must beirin over aofain. vet the same 
result is again obtained after each sponging. 
Which medication can accomplish as much? 
I have tried everything, and have finally 
remained faithful to this form of treatment. 

Exaggeration, as well as a systematic medi- 
cation for all cases, must be avoided. Each 
patient has Yellow Fever in an individual 
fashion and the treatment must vary according 
to the virulence of the disease. 

Light cases pursue their course toward re- 
covery without sponging, without bath. 

Cases in which the fever ranges between i : 
and 104 deg. are made very comfortable by 
sponging, which prevents the occurrence of 
complications, but recovery is possible without 



Treatment of Yellow Fever. 187 

its use. However, when the fever runs between 
104 and 105 deg. they are indispensable, while 
above 105 deg. they, together with the cold 
bath, give us the only medication which can 
sometimes obtain recover}'. 

This sponging or refrigeration in Yellow 
Fever, as in fact all medication, is a question of 
medical tact, with the advantage that it can 
never do harm ; badly done, it may not give good 
results, but it will not hurt, while, when well 
applied, it certainly saves many patients who 
would otherwise die. I believe that, without 
exaggerating, the mortality may in this wise 
be diminished by thirty per cent. 

Treatment of Vomiting. — Vomiting is a 
very painful and fatiguing symptom at the 
outset of Yellow Fever. The icteroid toxin 
has, according to Sanarelli, a very active emetic 
effect. 

After the invasion, the stomach ordinarily 
contracts and expels whatever it may contain. 
Being congested and very tender upon .press- 
ure, it is exceedingly irritable. Whatever the 
patient takes is vomited, whether it be reme- 
dies, food, or drink. Hence the indication is 
to allow the stomach the most complete and 
absolute rest. 



r88 Ykllow Fever. 

When consulted by a carpenter with a 
phlegmon of the hand, is he advised to con- 
tinue hammering with the ailing hand ? He is 
ordered to place his hand at rest, in a sling, 
and probably to poultice it. Why then at- 
tempt to compel a congested, painful and 
ailing stomach to continue working ; why 
irritate it, why make it try to digest or absorb ? 
By vomiting everything that is put in it, the 
stomach squarely says : " For goodness' sake 
let me alone." 

While this period of intolerance lasts, which 
is usually a very short time, give the stomach 
the most complete rest. 

Diet — Nourishment. — During the first 
seventy-two hours of Yellow Fever I give no 
nourishment whatever, not even milk or broth. 
Should the fever fall below 102 deg. previous 
to the third day, I then allow some milk, 
diluted Math Vichy water, every four hours. 

Graves, Dublin's great clinician, said one 
day to his pupils that if they were ever em- 
barrassed as to a choice of epitaph for him, to in- 
scribe on his tomb : " He fed fevers." If that 
eminent physician had ever treated Yellow 
Fever, he would have made an exception, for 
the lightest nourishment during the period of 



Treatment of Yellow Fever. 189 

congestion increases the fever and aggravates 
the disease, especially when the temperature 
goes beyond 103 deg. 

Imprudence in alimentation during the first 
three days has more serious consequences than 
imprudences in movement. It is disastrous to 
give solid food, but even milk or light broth 
cause indigestion and a return of gastric irri- 
tability. Starve your patient, whether he be 
child, adolescent or adult, and do not violate 
this rule except if the fever be below 102 deg.; 
one never dies of starvation in Yellow Fever 
for being deprived of food two and a half or 
three days, but death is often produced by 
recrudescence of the disease due to dietary im- 
prudence. 

Drixk — Vichy. — During the first three days 
of the disease allow the patient only Yichy 
water — Celestins. 

Thirty-two years ago I was called in consul- 
tation to see a young woman who was dying 
of Yellow Fever, and was under the treatment 
of a physician without much medical instruc- 
tion, but who passed in New Orleans as a 
great curer of Yellow Fever. I had at that 
time no experience in Yellow Fever, and never 
lost an occasion of deriving instruction by 



190 Yellow Flyer. 

causing such physicians as had seen and 
treated much of this fever to talk on the sub- 
ject. I asked my confrere to give the benefit 
of his experience, as say the Americans. 

" My experience is very simple," said he. 
" I first ask if the patient is urinating freely. 
If I am answered yes, I announce that the 
patient will recover. If I am told that he 
urinates very little or not at all, I shrug my 
shoulders, which means that the patient is 
lost." 

This queer fashion of making the prognosis 
impressed me. I was not long in finding that 
this original observation was partly truthful, 
and, following the succession of that idea 
coming from the empiric, I understood that if 
those recovered from Yellow Fever who uri- 
nated freely, the indication was to cause 
patients to drink freely, in order that they 
might have abundant urine. Remember that 
this was in 1866. Since that time, finding 
that the plan worked well, I have always 
allowed a great deal of cool and even iced 
water to 1113- patients, the tolerance of the 
stomach permitting. 

It was during the epidemic of 1878 that I 
noticed that Vichy water had a favorable 



Treatment of Yellow Fever. 191 

action on the stomach, that it quieted vomit- 
ing, and that it was imbibed in large quantit\~ 
without proving heavy, and was well absorbed. 
Children especially drink it with avidity and 
pleasure in large quantities without inconve- 
nience. 

I first noticed the happy effect of Vichy in 
the case of a nervous young woman who 
was much fatigued by incoercible vomiting. 
Nothing seeming to quiet the gastric contrac- 
tions, I ordered Vichy water with crushed ice. 
Much relieved, the patient exclaimed : " This 
water is a Godsend to the stomach !" From 
that time I gave my patients only Vichy and 
from one to two bottles in twenty-fours. 

When Bouchard published his work on the 
toxicity of urine, I understood why patients 
who urinate recover from Yellow Fever and 
w T hy copious drinks are so salutary ; until then 
I had done like the individual who had been 
composing prose without knowing it. It is be- 
cause the icteroid toxin is thoroughly diluted bv 
the abundant quantity of drink, because the 
blood and tissues are cleansed, and because the 
poison is eliminated by the urine. 

Thirst is always great in Yellow Fever ; the 
patient is constantly asking for water. Usually 



192 Yellow Fever. 

water is to be given only in moderation if the 
stomach is irritable. Here is the rule I follow : 
I prescribe at the outset of the treatment a 
quarter of a glass of Vichy every ten minutes, 
leaving the patient free to take it according to 
his taste either iced, cool, or at the temperature 
of the air. 

If the spasmodic contractions of the stomach 
are not very pronounced, Vichy arrests them 
and the vomiting in a surprising manner, espe- 
cially if it be iced. 

If the stomach is very irritable and the pa- 
tient vomits the Vichy even in small doses, I 
leave the organ absolutely at rest during one 
or two hours ; then the iced Vichy is to be 
tried again and is to be given to the patient ad 
libitum, on condition that it does not produce 
vomiting and is absorbed. . 

Should vomiting, continue after the second 
trial, as may occur in alcoholics and some 
nervous persons, I discontinue all drinks by 
way of the stomach and have an injection 
of two large glasses of Vichy given even- 
three hours, and often more frequently ; it 
must be given slowly in order not to irritate 
the intestines ; the patient must be made to 



Treatment of Yellow Fever. 193 

drink in this way, by the bowel, nntil the con- 
tractions of the stomach are quieted. 

It is very rare that Vichy is not borne from 
the start and, especially, that it is not taken 
with pleasure by the patient. All do not drink 
three or four quarts in twenty-four hours, but 
we must insist upon two quarts, and have 
them absorbed either by the stomach or by the 
intestine. 

Patients with high temperature have great 
thirst and much appetite for iced Vichy. 
Dispense it freely, for it is in cases of high 
fever that the lavage of the stomach and 
tissues and an abundance of urine are indis- 
pensable for obtaining a cure. Under the 
influence of repeated cold spongings and of 
large quantities of Vichy w r ater, diuresis be- 
comes active. The patient urinates at least 
every two hours, and the quantity of urine 
voided in twenty-four hours often reaches to 
two or three quarts or more. 

The more abundant the urine the less dan- 
ger in Yellow Fever, the fever falls, the gen- 
eral condition improves and the congestive 
pains disappear. 

The more copious the urine the less albu- 
minous it is ; icterus appears later, even in 



194 Yellow Fever. 

serious cases, and I once treated a patient 
whose temperature daily had been above 105 
deg., and was saved through an abundant secre- 
tion of urine due to the daily consumption of 
four quarts of Vichy. Notwithstanding the 
virulence of the toxin, evidenced by fever 
above 105 deg. during three days, the patient 
did not have albuminuria at any time. 

I consider Vichy water not only as an agree- 
able, useful, and indispensable drink in Yel- 
low Fever, but as a remedy of the highest 
order. The quieting of the stomach is due to 
the bicarbonate of soda which this water con- 
tains. All the secretions are very acid in Yel- 
low Fever, especially the secretions of the 
stomach and the kidneys. This explains the 
happy effects of alkaline drinks when given in 
abundance. (I have looked in vain in the 
memoirs of Sanarelli for a statement as to the 
reaction of his cultures or as to the acidity or 
alkalinity of the icteroid toxin.) 

We know that bicarbonate of soda increases 
the akalinity of the blood, acts as an antiphlo- 
gistic, and that an excess of it in the blood modi- 
fies hepatic function and brings it back to the 
normal. We know also that waters containing 
bicarbonate of soda stimulate the secreting 



Treatment of Yeeix>w Fever. 195 

organs, increasing diuresis and hepatic circu- 
lation. 

Finally, we know that alkaline drinks are 
indicated in acid conditions as gout, rheuma- 
tism, some forms of dyspepsia, and that they 
are very useful in such affections as are due to 
an excess of uric, lactic, or hydrochloric acid 
in the blood or the tissues. May not Yellow 
Fever be an acid disease, I might timidly asi^?-^ 

At any rate, the first lesion in Yellow 
Fever is fatty degeneration of the hepatic cell, 
the second being fatty degeneration of the 
renal parencl^ma ; hence, it may be that 
Vichy water produces such remarkable results 
in the treatment of Yellow Typhus by stimu- 
lating the hepatic circulation and urinary 
secretion ; by diluting, perhaps even neutraliz- 
ing, the icteroid toxin. 

It must be well understood that, in default 
of Vichy water, the patient must not be de- 
prived of the benefit of carbonated alkaline 
waters. That from the Celestins spring seems 
to be the Vichy preferred by patients. Lack- 
ing the Celestins, that from other springs can 
be given or water alkalinized by means of one 
drachm of bicarbonate of soda to the quart. 

Very good results can be obtained with this 



I 



1 96 Yellow Fever. 

artificial alkaline ' water, but, according to my 
experience, the patient drinks more freely and 
tires less quickly of the natural Vichy water. 

When the surgeon is about to perform an 
operation for the first time, he never complains 
of lengthy operative details to be found in his 
books ; I hope that the physician wishing to 
treat Yellow Fever according to the indications 
I have given will not find that their exposition 
has been too long or too minute as far as the 
period of congestion and the course of the disease 
are concerned. 

What Not to Do. — I have indicated what 
should be done in the treatment of a patient 
attacked by Yellow Fever, and would now like 
to say a word about what must not be done. 
It is good therapeusis to observe above all the 
old adage : " Primo non nocere ! " 

I no longer administer remedies in Yellow 
Fever, as, long ago I acquired the certainty 
that all drugs in this disease were useless or 
harmful. 

Sulphate of quinin was formerly adminis- 
tered; I administered it in 1866 and 1867; 
some physicians still give it to-day, influenced 
by the belief that this disease might be of 
malarial origin or belong to that family. The 



Treatment of Yellow Fever. 197 

discovery of the bacillus by Satiarelli has 
enlightened us on that point. Quinin is borne 
by the stomach only when not much con- 
gested; that is to say, in the light cases. When 
the fever is high and the vomiting persistent, 
quinin sinrply keeps up and increases gastric 
irritation, leading the way to black vomit. Its 
action is null on the fever, and more so on the 
infection. In children, whose stomach is very 
sensitive in Yellow Fever, quinin is never tol- 
erated, and, should it be insisted upon, the 
situation is likely to be made worse. 

In 1878, the physicians who yet believed in 
the malarial etiology of Yellow Fever lost 
nearly all the children they treated, because 
thev stuffed their patients with quinin. 

Repeated purgatives irritate the intestines 
and, by their excessive effect, too often 
weaken the patient considerably. A light 
purgative may be given with advantage at the 
outset. I prefer calomel and, later, enemata 
morning and night during the entire course of 
the disease. 

Preparations of digitalis, infusion of the 
leaves especially, have been frequently used by 
me ; they have a tonic action on the heart, 
causing the fever to fall, but, at the end of 



198 Yellow Fever. 

twenty-four hours, they irritate the stomach 
and have no favorable action on the course of 
the disease. I no longer give them. 

It is tempting to resort to the administration 
of the coal tar products : antipyrin, phenace- 
tin, antifebrin, etc. These remedies meet two 
indications — they are good analgesics and anti- 
thermics. In Yellow Fever they relieve the 
cephalalgia and rachialgia, and lower the tem- 
perature, but, unfortunately, their action is not 
limited to these two favorable effects. In large 
doses they decrease blood pressure, depress the 
nervous system considerably, and diminish the 
permeability of the kidneys and their depura- 
tive action, which is so precious and indispens- 
able in the toxi-infections like Yellow Fever. 
All distinguished clinicians and therapeutists 
who have written about these remedies have 
discarded them long ago, owing to the mishaps 
which they might bring about. In Yellow 
Fever the indications are to increase blood 
pressure, to sustain the nervous system, and to 
stimulate the urinary function — just the oppo- 
site of the effects produced by these dangerous 
agents. However, I have several times given 
a ten-grain dose of antipyrin in order to 
increase the defervescence produced by spong- 



Treatment of Yellow Fever. 199 

ing or bathing, when the patient was urinating 
abundantly and the temperature was above 105 
deg. But I never repeat the dose. 

Ice bags may be used without harm to the 
patient to relieve severe cephalalgia, epigastric 
pains, and frequent or incoercible vomiting ; 
they always produce a rapid sedative effect. 
For the rachialgia, I have the painful region 
lightly rubbed with a large piece of ice wrapped 
in flannel. 

These pains never constitute grave or dan- 
gerous symptoms. They diminish or disappear 
in twelve to twenty-four hours by means of 
the sponging. 

I need not say that hypodermic injections of 
morphin, or the administration by the stomach 
or bowel of any preparation of opium must 
never be resorted to for the relief of the pains 
of vomiting of the outset, or especially for 
black vomit. Opium is a violent poison in 
Yellow Fever, diminishing the urinary secre- 
tion during the period of congestion and totally 
arresting it during the period of infection. 

I object in the same manner to blisters. Can- 
tharides and opium both seal up the kidneys. 

Cocain is also a bad remedy, as it depresses 
the nervous system to a great extent. 



200 . Yellow Fever. 

Treatment During Period of Infection. 

Sanarelli appears to have accumulated con- 
clusive proofs, in his memoirs, of the discovery 
of the pathogenic bacillus of Yellow Fever. 
His anatomo-pathologic studies in man and in 
animals are so complete and well exposed that 
it is seen by reading them why we are dis- 
armed as to the treatment after organic lesions 
have supervened. 

His valuable clinical studies confirm what 
has been taught clinically, that we can aid in 
the patient's recovery only during the first 
three days of Yellow Fever. 

Once introduced into the organism, the bacil- 
lus icteroides produces a general intoxication 
which we can combat at the outset by proper 
treatment, thus preventing specific organic 
alterations. However, if the bacillus is too 
virulent, if the organism does not defend itself 
properly, or if the treatment does not secure 
the elimination of the toxin, the disease, ac- 
cording to Sanarelli, " brings about a rapid 
fatty degeneration of the histological element 
of the liver ; in the digestive tract, it produces 
hematogenous gastro-enteric lesions ; in the 
kidneys, it produces an acute parenchymatous- 
nephritis. The patient is threatened with three 



Treatment of Yeleow Fever. 201 

prominent dangers, and a bacteriologic exam- 
ination of the cadaver can approximately give 
testimony as to the principal cause of death. 

( 1. When the bacillus icteroides is found 
in the cadaver in reasonable numbers and in a 
state of relative purity, in the cases which 
follow the morbid cycle to the end, death may 
be considered as being due principally to the 
specific infection. 

" 2. When an almost pure culture of the 
other microbes is found in the cadaver, death 
may be considered as due to the septicemia 
produced during the course of the disease. 

"3. When the cadaver is found sterile and 
showing a large proportion of urea, death may 
be due to renal insufficiency." 

As is proved by my clinical charts, I had 
already seen and symptomatically differen- 
tiated the forms of death in Yellow Fever. 

These clinical and bacteriologic views un- 
happily do not yet yield therapeutic indica- 
tions. We are practically powerless to combat 
the hepatic cellular lesions and acute paren- 
chymatous nephritis. Neither have we any 
way of acting directly against black vomit, as 
it is due to lesions of the degenerated mucous 
membrane, to alterations of the blood, and, 



202 Yellow Fever. 

especially, to the rupture of capillary blood 
vessels. 

I have tried against the latter all the hemo- 
statics, astringents and coagulants known, and 
without success. I have never obtained good 
results with injections of ergotin. Absolute 
rest of the stomach has seemed to give me the 
best results; put nothing, not even a drop of 
water, within the bleeding organ, and apply 
an ice bag over the epigastrium. 

Following black vomit, the temperature falls 
suddenly eight and ten degrees — to 97 or 96 
deg.; the patient becomes cold, and I order 
frictions made with hot vinegar over the whole 
body; I have even given hot baths. 

If the pulse is weak and compressible, I try 
to stiengthen it by the subcutaneous injection 
of 1 milligram of digitalin or 25 centigrammes 
of caffein. If there is considerable nervous 
depression, I resort to hypodermic injections 
of ether, of cognac, or of camphorated oil. 
Inhalations of oxygen, which have a marked 
hemostatic action in other diseases, have been 
tried without result. 

At times, I give rectal injections of strong, 
black, mot coffee, to which are added two table- 
spoonfuls of brandy. I battle to the last. 



Treatment of Yellow Fever. 203 

I have often seen patients with, black vomit 
and in a desperate condition recover, without, 
however, being able to say this or that had 
done good, and besides, with the same sort of 
treatment, I have seen so many die. 

Recovery sometimes occurs after black vomit, 
when the temperature remains elevated between 
102 deg. and 103 deg. and hemorrhage is not 
very profuse or frequently repeated. It may 
be that in such cases secondary infections pro- 
duce septicemia and destroy the bacillus icter- 
oides, by means of their microbes and toxins. 

According to Sanarelli, the bacillus icteroides 
is found to be absolutely inferior in biologic 
conditions to resistance against the strepto- 
coccus, the bacterium coli, and the proteus. 

Septicemia due to the streptococcus or the 
coli bacillus is characterized by the lack of 
fall of temperature when black vomit occurs ; 
hence, it would seem to be less grave than the 
pure icteroid infection, and would sometimes 
be followed by recovery. 

However, these etiologic shades are not yet 
sufficiently understood clinically to give any 
therapeutic indications. 

When parenchymatous nephritis is very 
acute, all renal function is arrested, as well 



204 Yeixow Fever. 

as the organic nitration; hence, if together 
with the black vomit, uremic accidents follow : 
delirium, coma, convulsions, inhalations of 
oxygen might be tried, frequently repeated, 
to control these accidents. Intestinal de- 
rivation might be resorted to, following 
Jaccoud's treatment. Large enemata of 
cold, tepid or warm water intended to be 
retained, are indicated to combat suppression 
of urine. Lavage of the blood by means of 
Hayem's serum has been found useless. 

In all cases of very acute infection one can 
only repeat after Faget, when confronted by a 
case of chronic tuberculosis or of cancer : 
" Poor Medicine !" 

I have often seen patients recover after 
having had black vomit, even after having 
had suppression of urine for a few hours; 
but, after having emplo3^ed the means just 
indicated, even subsequent to recover} 7 , I have 
remained modest^ persuaded that the or- 
ganism itself had worked out its own salvation 
by means absolutely ignored by me. 

In 1867, I was treating a young woman who 
had abundant and repeated black vomit, ac- 
companied by scantiness of urine on the fourth 
day of Yellow Fever. I thought the patient 



Treatment of Yeeeow Fever. 205 

lost, when, the next day, my attention was 
called to a large, red, inflamed and fluctuating 
abscess which had formed in twenty-four hours 
on the upper third of the right thigh. I 
promptly opened and emptied this abscess and 
my patient recovered. Since then I have seen 
three other cases of very grave Yellow Fever, 
with black vomit, in which formation of pus was 
followed by recovery ; hence, I have been ac- 
customed to say that when pus is formed 
during the course of Yellow Fever recovery 
follows. 

These observations were recalled when, a 
few years ago, Professor Fochier, of Lyons, 
proposed as a last resort in infectious diseases 
the subcutaneous injection in the cellular 
tissue of four or five drops of essence of tur- 
pentine to produce large abscesses. I was 
struck by the connection betweeen the ideas of 
Fochier and my observations in Yellow Fever. 
Fochier and others have reported recoveries in 
desperate cases of septicemia, principally 
puerperal, obtained by these injections. 

I had proposed to try these injections in 
hopeless cases, but I did not see a single case 
of black vomit during the epidemic of 1897. 
This medication should be tried. 



206 Yellow Fever. 

The mortality in Yellow Fever has greatly 
diminished since the great epidemic of 1853. 
I believe that by means of proper treatment 
the tribute paid to the Yellow ogre can be fur- 
ther reduced, while awaiting the prophylactic 
and curative serum expected of Sanarelli. 




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